CLINICAL RECORD DOCUMENTATION MANUAL FOR

OUTPATIENT SPECIALTY MENTAL HEALTH SERVICES

Butte County Department of Behavioral Health

May 2013

CLINICAL DOCUMENTATION MANUAL FOR

OUTPATIENT SPECIALTY MENTAL HEALTH SERVICES

BUTTE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH

April 10, 2015Updated

i

To partner with individuals, families and the community for recovery from serious mental

health and substance abuse issues and to promote wellness, resiliency and hope.

The following core values are fundamental to our actions and reflect how we choose to

conduct ourselves. Although our external environment may vary greatly, these values remain

constant. Our commitment to these values will guide our actions and be consistently reflected

in our relationships with one another, our clients, our community partners and providers.

RESPECT: We will honor the value of all individuals and their experiences.

GRACE: We hold the trust of others through kindness and respect.

DIGNITY: We believe in an individualized approach to care that honors the person.

HOPE: Is a life-affirming component to self-determination, recovery and resiliency.

SELF-DETERMINATION AND GROWTH: As individuals, we have the right to determine how

we live. Change is always possible.

DIVERSITY: Embracing and respecting diversity is vital to an individual’s and community’s

success.

COLLABORATION: Working together through integrity and the collective wisdom of our

partners, we become stronger.

EFFICIENCY AND ACCOUNTABILITY: We are stewards of the public trust.

EXCELLENCE IN PREVENTION, TREATMENT AND CARE: We will provide continuity in

prevention, treatment and care with a minimum of delay and the best possible outcomes for

the individuals and families we serve.

CORE VALUES

MISSION

Return to Top of Section Return to Table of Contents

ii

For the Department’s vision, we sought to develop a statement that appealed to our core

values, yet was simple in serving as a guide and providing focus. Our vision is:

“A continuum of care that promotes the behavioral health of the entire community.”

Butte County Department of Behavioral Health (BCDBH) values our clients and encourages

each client to participate in his/her care. With this in mind, we encourage our staff to involve

clients in his/her documentation when appropriate to include using client(s) own words when

applicable. Our desire is to partner with our clients in care to promote wellness and recovery at

every step of care.

Butte County Department of Behavioral Health Department has produced the Clinical

Documentation Manual to serve as a guide for all clinical chart records, but does not take the

place of clinical supervision. This manual serves as a guidance document to promote excellent,

accurate and timely documentation of the services we provide to our community. We strive to

provide excellent care to our clients, and accurate documentation is a crucial step in the

process of delivering excellent care. A client’s chart should depict a comprehensive record of

treatment and have a “flow” often referred to as “The Golden Thread”.

APPLICATION

Managers and supervisors are encouraged to use the documentation manual as a reference

and resource to train staff. The documentation manual defines key concepts, explains

documentation requirements, and provides examples of how to document various types of

mental health services. All staff providing clinical services should refer to the manual

whenever they need an answer to a documentation question.

Inevitably, situations arise when staff will need clarification or further direction. In such cases,

the program manager or supervisor should be consulted. Quality Management staff will be

available to address any further questions concerning documentation.

VISION

PHILOSOPHY

OVERVIEW

Return to Top of Section Return to Table of Contents

iii

The manual will be used for all client* records regardless of payer source. Specialty programs

within the department may have unique documentation requirements (i.e. a grant funded

program may have specified additional items to include in the chart). Samples and examples

are meant to illustrate the topic and are not meant to replace clinical supervision or sound

clinical judgment.

*Note: A client is a person who accesses and receives outpatient mental health services; a

client is also known as individual, patient, consumer, beneficiary, etc.

SOURCES OF INFORMATION

This Clinical Documentation Manual is to be used as a reference guide and is not a definitive

single source of information regarding chart documentation requirements. This manual

includes information based on the following sources: the California Code of Regulations (Title

9), the California Department of Health Care Service’s (DHCS) letters/notices, the Butte

County Department of Behavioral Health’s (BCDBH) policies & procedures, directives, and

memos; and Quality Management’s interpretation and determination of documentation

standards.

ORGANIZATION & SYMBOLS

This manual is organized into color-coded sections and clickable links to help you navigate it

with as much ease as possible. This manual contains many links connecting you to either

online resources or to other parts of the document. If ANY word or phrase is underlined, this

means that it can be clicked on for instant access to another part of the manual; these are

called “Section Shortcuts.” The following symbols and graphics are used to help bring clarity

and simplicity to the manual as a whole:

These can be found throughout this document and provide answers to some

frequently asked questions. All 'Documentation Tips' will be denoted with the

above graphic with italicized and turquoise-blue colored text below the graphic.

This symbol indicates that you should pay careful attention to the following

information. The information will be clearly labeled with "CAUTION".

DOCUMENTATION TIP

!

Return to Top of Section Return to Table of Contents

iv

Each section will be denoted with a special symbol relating to the subject of the

section (the example to the left is for the “Scope of Practice” section). The entire

section will utilize the symbol and the colors of the symbol.

This mouse and link symbol indicates an internet link. These links will be

clickable in the PDF format.

This indicates a clickable “section shortcut” to the Table of Contents or head of

the section. It appears below every page number within this manual. The

intention is that if you click on a “section shortcut” within the Table of Contents

and are taken to the desired section, you have a shortcut that can take you back

to the Table of Contents in case you wish to jump to another part of the manual.

Click on the hexagon for a demonstration.

TECHNICAL ASSISTANCE

The Quality Management staff is available to answer questions about this documentation

manual or documentation issues in general. You can reach us at 530.879.2456

T

C

LINK

DELL

Return to Table

of Contents

Return to Top of Section Return to Table of Contents

Return to Top

of Section

v 

TABLE OF CONTENTS 

Mission Statement ................................................................................................................... i 

Core Values .............................................................................................................................. i 

Vision ....................................................................................................................................... ii 

Philosophy ................................................................................................................................ ii 

Overview .................................................................................................................................. ii 

Application .................................................................................................................... ii 

Sources of Information ................................................................................................. iii 

Organization & Symbols ........................................................................................... iii‐iv 

Technical Assistance .................................................................................................... iv 

SECTIONS 

I. Scope of Practice .......................................................................................................... 2 

II. Informed Consent .........................................................................................................5 

III. Medical Necessity ........................................................................................................ 6 

Medical Necessity Criteria .............................................................................. 6‐8 

IV. Assessment .................................................................................................................. 9 

Assessment Timeline .................................................................................. 10‐12 

V. Treatment Plan ........................................................................................................... 13 

Treatment Plan Timeline ............................................................................. 14‐15 

Treatment Plan Components ...................................................................... 15‐21 

Problems .............................................................................................. 15 

Goals .................................................................................................... 16 

Strengths ......................................................................................... 16‐17 

Objectives (Template Included) ....................................................... 17‐18 

Interventions (Template Included) ................................................... 18‐20 

Signatures ....................................................................................... 20‐21 

Therapeutic Behavioral Services ........................................................... 21 

VI. Dual Diagnosis ...................................................................................................... 22‐24 

T

C

Return to Top of Section Return to Table of Contents 

vi 

 

VII. Discharge .................................................................................................................... 25 

VIII. Documenting by Service Type – Progress Notes 

Progress Notes .................................................................................... 26 

General Rules for Progress Notes .................................................... 26‐28 

Mental Health Services – Assessment (3310) ................................... 28‐29 

Mental Health Services – Plan Development (3910) ..........................29‐30 

Mental Health Services – Collateral (3110) ........................................ 30‐31 

Mental Health Services – Rehabilitation (3450) ................................ 31‐33 

Mental Health Services – Therapy (3410, 3412, 3414, 3415) .............. 33‐34 

Targeted Case Management (3030) ................................................. 34‐35 

Mental Health Services – Crisis Intervention (3710)................................ 36 

Medication Support Services ................................................................ 37 

Special Populations – Progress Notes 

Katie A Subclass –  Intensive Care Coordination (3040) .................... 37‐38 

Katie A Subclass – Mental Health Services – Intensive Home Based 

Services (3420) ..................................................................................... 38 

Mental Health Services – Therapeutic Behavioral Services (3230) .... 39‐40 

Services & Descriptions Pertaining to Medical Staff ........................................ 40 

IX. Non‐Reimbursable Services.................................................................................... 41‐42 

X. Lock–Outs ..............................................................................................................43‐44 

XI. Documentation Examples 

Adult Example List ........................................................................................... 45 

Youth Example List ......................................................................................... 46 

 

Return to Top of Section Return to Table of Contents 

vii 

GLOSSARY ........................................................................................................................... 118 

APPENDIX 

A. Medical Necessity Criteria – Diagnoses .................................................................... 119‐120 

B. BCDBH Chart Paperwork Timelines ......................................................................... 121‐122 

C. BCDBH Procedure Code Definitions ......................................................................... 123‐134 

Procedure Codes for Direct Services ............................................................. 123‐125 

Procedure Codes for Medical Staff ................................................................ 126‐127 

Procedure Codes for Special Populations ............................................................. 128 

Procedure Codes for “Lock–Out” Settings .................................................... 129‐131 

Procedure Codes Definitions – Indirect Services ............................................. 132‐133 

Procedure Codes for “Limited/Restricted to Designated Staff Only” .................... 134 

D. Format for Progress Notes ........................................................................................ 135‐137 

E. Billing “Lock–Out” Grid ................................................................................................... 138 

Return to Top of Section Return to Table of Contents 

1

Our guide on the scope of practice and answers the basic question: “Who can provide each service?”

Provides information regarding informed consent

Covers medical necessity and how to establish this for each client prior to delivering any service and throughout client care.

Provides detail on how to complete a clinical assessment and a clinical treatment plan. Gives detailed information on what is expected to be included in each of these forms/options.

Addresses all of the service activities that are reimbursable. We’ve provided definitions, descriptions of the activities, and other useful information.

Introduces dual diagnosis and how to properly identify and write a dual diagnosis.

Presents some general guidelines for the discharge process.

Presents some general guidelines for writing progress notes.

Addresses activities that are not reimbursable. Take note that this list has been expanding over the years.

Simplifies the lockout rules.

Shows examples of chart documentation (fictitious clients); Section for demonstration purposes only. Please follow the manual instructions on dates and timelines.

Section I

Section III

Section IV

Section V

Section VI

Section VIII

Section IX

Section II

Section X

Section XI

Section VII

Sections

Return to Top of Section Return to Table of Contents

2

It is expected that staff will provide services allowed in their job classification and by

credentials (i.e. licensure, Board registration, education, training, and experience). Further

limitations may be due to level of experience in a specific service category or by

department restrictions.

STAFF ELIGIBLE TO PROVIDE SERVICE SERVICE ACTIVITIES

Physicians, Nurse Practitioners

Assessment Plan Development Crisis Intervention Collateral Individual Therapy Family Therapy Group Therapy Rehabilitation (individual, group)/Intensive

Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination Therapeutic Behavioral Services Medication Support (education, monitoring) Medication Administration Medication Evaluation

RN with Master’s in Mental Health Nursing

Assessment Plan Development Crisis Intervention Collateral Individual Therapy Family Therapy Group Therapy Rehabilitation (individual, group) /Intensive

Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination Therapeutic Behavioral Services Medication Support (education, monitoring) Medication Administration

Registered Nurse with ADN or BSN

Nursing Assessment Only Plan Development Crisis Intervention Collateral Rehabilitation (individual, group) /Intensive

Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination Therapeutic Behavioral Services Medication Support (education, monitoring) Medication Administration

I. SCOPE OF PRACTICE

Return to Top of Section Return to Table of Contents

3

STAFF ELIGIBLE TO PROVIDE SERVICES SERVICE ACTIVITIES

Licensed Vocational Nurse & Licensed Psychiatric Technician

Nursing Assessment Only (with co-signature) Plan Development Crisis Intervention Collateral Rehabilitation (individual, group) /Intensive

Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination Therapeutic Behavioral Services Medication Support (education, monitoring) Medication Administration

Behavioral Health Clinicians (BBSE Registered Interns and Licensed)

Assessment Plan Development Crisis Intervention Collateral Individual Therapy Family Therapy Group Therapy Rehabilitation (individual, group) /Intensive

Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination Therapeutic Behavioral Services

Behavioral Health Counselors

Crisis Assessment Plan Development Crisis Intervention Collateral Rehabilitation (individual, group) /Intensive

Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination Therapeutic Behavioral Services

Behavioral Health Workers

Crisis Intervention (when co-signed by licensed staff)

Brokerage / Targeted Case Management/Intensive Care Coordination

Family Partner, Peer Advocate, and Behavioral Health Education

Specialist

Plan Development Crisis Intervention (when accompanied by

licensed staff) Collateral Rehabilitation Services (individual, group)

/Intensive Home Based Services Brokerage / Targeted Case

Management/Intensive Care Coordination

Return to Top of Section Return to Table of Contents

4

STAFF ELIGIBLE TO PROVIDE SERVICES SERVICE ACTIVITIES

2nd Year Graduate Student Intern (ex. MSW 2nd year, MFT Trainee)

& One-year program Graduate Student

Interns

Assessment* Plan Development* Crisis Intervention* Collateral* Individual Therapy* Group Therapy* Family Therapy* Rehabilitation Services (individual, group)

/Intensive Home Based Services * Brokerage / Targeted Case

Management/Intensive Care Coordination *

*All services require a co-signature by licensed staff.

1st Year Graduate Student Intern

Plan Development* Crisis Intervention* Collateral* Rehabilitation Services (individual, group)

/Intensive Home Based Services * Brokerage / Targeted Case

Management/Intensive Care Coordination *

*All services require a co-signature by licensed staff.

Undergraduate Student Interns

Plan Development* Collateral* Rehabilitation Services/Intensive Home

Based Services * (individual and group**) Brokerage / Targeted Case

Management/Intensive Care Coordination * *All services require a co-signature by licensed staff. **Group Rehabilitation Services can only be provided with a BCDBH Staff co-leader.

Return to Top of Section Return to Table of Contents

5

Informed Consent

Informed Consent for Treatment must be obtained prior to providing services (first

face-to-face contact) to a client and is the first step to be completed between the clinician*

and the client or the client’s parent/guardian. Per Title 22, section 101, “informed consent

means that a [client] grants, refuses or withdraws consent to treatment after the MH provider

presents the [client] with information about the proposed mental health services, mental

health supports, or treatment, in language and manner that the [client] can understand”. At

BCDBH, we obtain written informed consent at the initial admission (first face-to-face contact)

to services and annually thereafter. This consent covers both outpatient and inpatient services

and is valid unless the client withdraws the consent. Discussion about informed consent must

be documented in the client’s clinical record. If a client is unwilling or unable to provide

informed consent the reason, as well as attempts to obtain informed consent must be

documented in the client’s clinical record.

For treatment with psychotropic medications there are additional documentation

requirements for informed consent. Consent for Psychotropic Medication Therapy must be

completed by the medical staff prescriber and the client or the client’s parent/guardian. This

documentation shall include, but not be limited to, the reasons for taking such medications;

reasonable alternative treatments available, if any; the type, range of frequency and amount,

method (oral or injection), and duration of taking the medication; probable side effects;

possible additional side effects which may occur to clients taking such medication beyond

three (3) months; and that the consent, once given, may be withdrawn at any time by the

client. Medication consent must be obtained prior to prescribing medication and whenever a

new medication is prescribed.

*During a crisis on an unopened client, it is permissible for a behavioral health counselor to

obtain informed consent during the face-to-face contact.

II. INFORMED CONSENT

Return to Top of Section Return to Table of Contents

6

II. Medical Necessity

Butte County Department of Behavioral Health conducts a brief screening assessment

with clients to establish medical necessity.

The screening includes completion of the following options in the Electronic Health Record

(EHR):

Informed Consent

BCBDH Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Guide to Medi-Cal Mental Health Services

BCDBH Medical Necessity Determination

BH Mental Status Exam

BCDBH Diagnosis.

If a client meets medical necessity, an initial assessment and a treatment plan will also be

completed. The initial assessment must include all diagnostic criteria required in the DSM to

support the primary diagnosis and describe the functional impairments that significantly

impact the client’s day-to-day life. All long term clients are required to have an initial

assessment and treatment plan on record.

Note: Any client open for 60 days or greater is considered a long term client.

Clients must meet the following medical necessity criteria as described in Title 9 (§1830.205, 1830.210) in order to be eligible for outpatient specialty mental health services: The client must have an included qualifying current Diagnostic and Statistical Manual

(DSM) mental health diagnosis that is the focus of treatment. See APPENDIX A for a list of

included and excluded diagnoses

As a result of the mental health diagnosis, there must be one of the following criteria:

a. A significant impairment in an important area of life functioning (e.g., Living

Arrangement/Housing, Activities of Daily Living, Primary Support Group,

Education, Financial Economic Issues, Access to Health Care Services, Social

Relationship/Environment/community, or School Situation)

MEDICAL NECESSITY CRITERIA

III. MEDICAL NECESSITY

Return to Top of Section Return to Table of Contents

7

b. A reasonable probability of significant deterioration in an important area of life

functioning

c. For a child (a person under the age of 21 years), a reasonable probability that the

child will not progress developmentally as individually appropriate

Must meet each of the interventions criteria listed below:

a. Focus of the proposed intervention must address the condition identified

b. The proposed intervention will do, at least, one of the following:

i. Significantly diminish the impairment

ii. Prevent significant deterioration in an important area of life functioning

iii. Allow the child to progress developmentally as individually appropriate

c. The conditions would not be responsive to physical health care based treatment

(Primary Care Physician)

Medical Necessity is gathered on the Medical Necessity Option in MyAvatar (See SECTION XI

for a sample of a completed Medical Necessity Determination form).

The Medical Necessity Determination Form is also used as the annual assessment by

right clicking in the presenting problems box >selecting System Templates >Annual

Assessment. This will incorporate additional questions that need to be answered

annually.

When a client is found to not meet medical necessity during a screening appointment, a

NOA-A must be issued to the client by the clinician, if they are a Medi-Cal beneficiary. For

additional information about NOA’s, please see Notice of Action policy.

In order to meet Medical Necessity Regulation, every note and every document (treatment

plan, assessment, medical necessity determination, etc.) must be unique and an accurate

description of the client’s current state at the time that documentation is written.

Each document must be able to “stand alone” and therefore meet medical necessity criteria

without referring to another document. This includes every document in the chart we use to

ensure we meet Medi-cal billing requirements.

DOCUMENTATION TIP

Return to Top of Section Return to Table of Contents

8

Examples:

1) Treatment plans: should be unique and are meant to be updated annually or more

frequently as the client either makes progress, or his/her needs or goals change.

Treatment plans remaining the same each year can potentially be viewed as if our

services are not helping or that we really are not in tune with our client’s goals.

2) Assessments/Medical Necessity Determination/Mental Status Exams: client’s not only

age each year, but will have likely made some life changes, have at least some

symptom differences, and have a response to our treatment that can be accurately

captured in an annual assessment. It should be an update and include a summary of the

client’s care and services over the past year. Documents that are capturing the client’s

current functioning such as a Mental Status Exam, should not be exactly as the year

prior as well. It would be expected that at least some changes are present due to

treatment.

3) Progress notes: each time a client comes in for a service, each progress note should

“stand alone” and include the client’s unique presentation and response to our

intervention in each session. Notes that are exactly the same each week, or have very

little variance are not only subject to disallowance, but can indicate a quality of care

concern, or be viewed as fraud or abuse.

CAUTION: BCDBH does not allow for Cut and Paste templates or cloning of any

kind to be used in our medical records. !

Return to Top of Section Return to Table of Contents

9 

 

The mental health assessment serves as the foundation for the client’s plan of care. The 

assessment reinforces eligibility to receive outpatient specialty mental health services, drives 

the treatment planning process, and provides the basis for ongoing changes in treatment 

delivery and discharge planning.  

 

 

1. A description of the client’s current symptoms and behaviors that supports the required 

DSM criteria for each diagnosis (including severity, frequency, duration, etc.) 

2. All sections must be completed (use N/A if not applicable).  It is not acceptable to leave 

questions or sections blank 

3. A detailed description of the client’s functional impairment(s) 

4. A list of the client’s strengths, in achieving client plan goals: 

a. Abilities and accomplishments 

b. Interests and aspirations 

c. Recovery resources and assets 

d. Unique individual attributes 

5. A description of the client’s cultural/spiritual/linguistic factors which may include: 

ethnicity, gender, spiritual beliefs, beliefs around birth/death,  family traditions, healing 

rituals, view of authority figures, family structure/dynamics, roles, how conflict is 

handled, military service. 

6. Substance Exposure/Substance Use. Past and present use of tobacco, alcohol, caffeine, 

complementary and alternative medications (CAM), over‐the‐counter (OTC), and illicit 

drugs these questions are embedded in the Medical Necessity Determination Form. 

a. If a substance‐related diagnosis is indicated, it must be included on Axis I.  

7. Both the numerical code and full clinical name of the diagnosis should be listed, based 

on the department recognized DSM.  For example, “Axis I: 313.81, Oppositional Defiant 

Disorder.”  

8. A full Five Axial Diagnosis must be completed. 

a. Please note Alcohol and Drug Diagnosis shall be listed as a Secondary Diagnosis 

on Axis I; if the Alcohol and Drug Diagnosis is the client’s primary diagnosis the 

     IV. ASSESSMENT 

AN EXCELLENT INITIAL OR UPDATED ASSESSMENT MUST INCLUDE: 

Return to Top of Section Return to Table of Contents 

10

client does not qualify for specialty mental health services and the client should

be provided a referral to Alcohol and Drug Services.

9. Any updated diagnosis must be accompanied by a progress note in order to document

the change, and the BCDBH diagnosis option in MyAvatar must be completed with the

updated information. In the event of a new or updated diagnosis, the treatment plan

will be reviewed and updated as necessary.

The assessment bundle in MyAvatar must be completed for all long term clients and includes

the following Documents:

Informed Consent

BCDBH Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Guide to Medi-Cal and Mental Health Services

BCDBH Medical Necessity Determination

BCDBH Diagnosis

BCBDH Initial Assessment

BH Mental Status Exam

Additional documents required include:

Release of Information (as appropriate)

Treatment Plan

CANS (for Children)

MORS (for Adults)

The initial mental health assessment is required for all clients meeting medical

necessity who are not currently opened or are new to the outpatient mental health

system (or are returning for services after being discharged from all outpatient

services for more than 30 days). This assessment shall be completed within 60

calendar days of the client’s signature on the consent to treatment form or that of

the legal guardian or adult. Assessments are considered valid* only when signed by

a LPHA* and finalized in the EHR (the date of validation appears by the LPHA staff

Assessment Timeline

1st 2nd 3rd

1. INITIAL ASSESSMENT

CONTENT

Return to Top of Section Return to Table of Contents

11

signature). Please refer to the BCDBH Chart Paperwork Timelines in APPENDIX B

for timelines and due dates for each item required in the clinical chart.

An updated assessment must be completed annually on or before the informed

consent date.

o This can be done using the Medical Necessity Determination Form by right

clicking in the presenting problems box >selecting System Templates

>Annual Assessment. This will populate additional questions needed to

make the Medical Necessity Determination Form act as the updated

assessment.

Updated assessments are required to be comprehensive and complete. In other

words, the updated assessment must stand alone and not simply be the same as the

initial assessment or initial medical necessity determination form. When completing

an updated or annual assessment the clinician must complete a new form.

Updated assessments must clearly state why the client continues to require services

in the presenting problem section of the assessment and in the medical necessity

determination form ( i.e. this is what establishes continued medical necessity)

Updated assessments must contain a summary of the treatment provided in the

past year and the response to that treatment.

Clients who are discharged from all open programs and return for

services within 30 days or less can be re-opened without having

to re-do all opening paperwork. Consents, assessments,

treatment plans, etc. can be defaulted from a previous program

as long as the information is current and was previously

completed less than one year ago.

You must be able to justify why treatment shall continue, for

example: “If a client has received individual therapy each week

for a year and has not made significant progress why would we

continue this same frequency, duration, and type of treatment?”

DOCUMENTATION TIP

2. UPDATED/ANNUAL ASSESSMENT

Return to Top of Section Return to Table of Contents

12

If an open client transfers to a new program or is added to a new program, the clinician may use one of the following three options:

1. Complete a new assessment within 30 calendar days of opening in the new

program, if indicated.

2. Accept the prior assessment, if satisfactory, as long as it was completed within

the past year and attest that they have pulled the document forward and not

made any changes. This assessment must be updated within a year of the

existing annual informed consent signature date.

3. If there have been changes or the prior assessment is incomplete the clinician

must complete a new initial assessment within 30 calendar days in the

assessment (refer to SECTION XI) for examples.

T

C

3. ASSESSMENTS WHEN CLIENT TRANSFERS TO OR ARE OPENED TO A NEW PROGRAM

Return to Top of Section Return to Table of Contents

13

Whereas the assessment documents the current mental health condition and functional

impairments of the client, the Treatment Plan is the guiding force behind the delivery of care.

The plan helps the client and the clinical staff to collaborate on the client’s recovery goals.

Ultimately, treatment should result in services provided at the lowest level of care needed or

discharge to the community. For an example of a treatment plan see SECTION XI.

The Treatment Plan is an agreement between the client and the clinician that states

which mental health problem(s) will be the focus of treatment. The Treatment Plan

consists of specific goals, objectives, and the treatment interventions that will be

provided (See “Signatures” at the end of this section).

There needs to be a clear connection and flow from the DSM diagnosis and functional

impairments in the assessment to the problem, goal, objectives, and interventions in

the treatment plan.

A Treatment Plan is required to be completed with all required signatures in each

outpatient mental health episode. There are no exceptions! The Treatment Plan shall

be used for all service activities.

A client receiving both general mental health and medication support services will have

an “integrated treatment plan.” Integrated plans include both general mental health

interventions and medication interventions. If the client is receiving integrated

treatment the LPHA is encouraged to coordinate care with the psychiatrist or

prescriber as needed to provide continuity of care and inform the treatment planning

process.

The Treatment Plan is only valid from the date in which both the LPHA and the client

have signed the plan. In the event of a new diagnosis, a new Treatment Plan may be

needed if clinically appropriate. Please consult with your clinical supervisor if needed.

BCDBH requires a minimum of two objectives with two interventions per objective on

each treatment plan.

V. TREATMENT PLAN Tx

OVERVIEW

TREATMENT PLAN BASICS

Return to Top of Section Return to Table of Contents

14 

 

Please note the only services that can be provided prior to the completion of a treatment 

plan (must be within 60 days) are assessment (3310), plan development (3910), and crisis 

intervention (3710/3715). 

 

 

 

The completion of the Treatment Plan is subject to specific deadlines and signature 

requirements, as described below: 

 

An initial plan can occur in two primary instances: new to services or transferring to a 

new program.  

1. New to Services: The initial Treatment Plan shall be completed within 60 days 

of the client’s entry to a program RU. This deadline applies to clients who are 

new to BCDBH or are re‐entering services after previously being discharged.  

2. Transfer: For existing clients who enter a new program or if the client transfers 

to a different program, the plan if still appropriate can be pulled forward* and 

utilized in the new program.  When pulling a document forward, the person 

pulling it forward will attest that they have pulled it forward and not made any 

changes.   In order to bill for services in a new program, each client must have a 

valid treatment plan within that treatment episode. 

 

Check the content and the dates of the plan to be sure the services you will deliver are 

covered in the plan.  If you do not agree with the current plan, update it with the client! 

 

Each Treatment Plan can be authorized for up to one year, however many clients 

achieve goals prior to a year, and plans shall be updated prior to a year based on goal 

achievement.  A plan should not be the same year after year.  If our current plan did not 

help the client achieve his or her goals, the plan must change.  If the current plan did 

work, update to reflect the changes.   

DOCUMENTATION TIP 

Treatment Plan Timeline 1st   2nd   3rd  

Tx 

DOCUMENTATION TIP 

1. INITIAL 

2. RENEWAL 

Return to Top of Section Return to Table of Contents 

15

An annual treatment plan must be completed on or before the expiration of the

informed consent date.

For example, the initial informed consent is signed on 5/2/13, the initial

treatment plan is completed on 6/30/13; the annual treatment plan will be due

on or before 5/1/14.

Subsequent treatment plans will be due prior to the expiration of the most

recent informed consent date.

For a complete list of all documentation timelines please see the Chart Documentation

Timelines in APPENDIX B.

If the renewal period passes and the next Treatment Plan is completed late, there will

be unauthorized days that should not be claimed (i.e. the renewal date is July 1st but the

Plan is completed on July 7th, then July 1st through 6th would be unauthorized for all

services, except crisis intervention, during that time period).

The treatment plan contains the following components to identify the needs and services of

the client: Problems, Goals, Strengths, Barriers to Treatment, Objectives, Interventions, and

Signatures.

The problem is the focus of treatment based on the mental health diagnosis, which includes

symptoms, behaviors, and life functioning.

Example: A client diagnosed with Schizophrenia – may have symptoms such as

auditory hallucinations, delusions, disorganized thinking, poor hygiene, social

withdrawal, or other issue that may interfere with securing stable housing and/or

maintaining positive family relations or otherwise impact his/her life functioning.

Example: A client diagnosed with Oppositional Defiant Disorder – may have symptoms

such as arguing with adults, yelling and screaming, temper tantrums, blaming others,

or not taking responsibility which impacts his/her life functioning at school.

3. LATE RENEWAL

PROBLEMS

TREATMENT PLAN COMPONENTS

Return to Top of Section Return to Table of Contents

16

In some cases, there may be two diagnoses that are the focus of treatment (e.g. Bipolar

Disorder & PTSD), so there could be two problems identified.

PERFECTING THE “PROBLEM” STATEMENT An excellent problem section will include the client’s impairment in life functioning that is

related to the diagnosis, i.e. maintaining housing.

Good Example: Client has depressive symptoms of insomnia, isolation, social

withdrawal, decreased appetite, suicidal ideation, and poor concentration, which

interferes with client’s ability to achieve daily activities such as work or school.

Another Good Example: Client’s psychiatric symptoms of schizophrenia are

evidenced by disorganized thoughts, irritability, paranoid ideations, auditory and

visual hallucinations which lead to difficulties maintaining housing.

Example of a Poorly Written Problem: Client has symptoms of major depressive

disorder (specific symptoms/functional impairments are missing).

The goal is the client’s desired outcome associated with their problem. This is where we help

the client articulate what life could be like without the problem, or with better coping with the

problem.

The goals should be stated in the client’s words whenever possible.

Example: Billy would like to have more friends. Or “I would like more friends.”

Example: Diane desires to live independently. Or “I would like to live in my own

apartment.”

Environmental factors that will increase the likelihood of success such as:

Community supports, family/relationships, support/involvement, work, etc. may be

unique to racial, ethnic, linguistic and cultural (including lesbian, gay, bisexual and

transgender) communities

Identifying the person’s best qualities/motivation

Strategies already utilized to help (what worked in the past)

Competencies/accomplishments interests and activities, i.e. sports, art identified by the

consumer and/or the provider

T

C

GOALS

STRENGTHS

Return to Top of Section Return to Table of Contents

17

Motivated to change

Has a support system – friends, family

Employed/does volunteer work

Has skills/competencies: vocational, relational, transportation savvy, activities of daily

living

Intelligent, artistic, musical, good at sports

Has knowledge of his/her disease

Values medication as a recovery tool

Has a spiritual program/connected to a church

Good physical health

Adaptive coping skills/ help seeking behaviors

Capable of independent living

Use the information on strengths (including cultural strengths) to identify the individual/family

attributes and skills. Identify resources that will be particularly significant to supporting the

client in achieving their goals

When considering strengths, it is beneficial to explore other areas not traditionally considered

“strengths,” Such examples include: an individual’s most significant or most valued

accomplishment, what motivates them, educational achievements, ways of relaxing and

having fun, ways of calming down when upset, preferred living environment, personal heroes,

most meaningful compliment ever received, etc.

An objective is a description of what the client will do to show progress toward a goal.

An objective will:

1. Address a problem (functional impairment)

2. Be observable and/or measurable

3. Have baseline and target levels

Objectives should not be absolutes, that is, we should not expect a person exhibiting a behavior

8 times per day at baseline to go to 0 times per day to achieve the objective. With the

exception of physical assault or sexual perpetration on others, this should always have a goal of

0 times per day. Smaller and more reasonable steps can assist in successes in the client’s life

and motivate towards goal achievement.

OBJECTIVES

Return to Top of Section Return to Table of Contents

18

Remember, you can always update the plan when a goal is achieved, so a movement

from 8 times per day to 5 times per day, for example, can be updated once achieved to

assist that movement from 5 times per day to be 2 times per day etc. Success breeds

success.

It is important to track client progress on objectives closely. Update the treatment plan as

needed or begin transitioning the client to a lower level of treatment or discharge when

objectives have been met or functioning has been restored.

The ‘Objective Template’ below can assist in writing a simple but

excellent objective.

OBJECTIVE TEMPLATE:

to TARGET

EXAMPLES OF A GOOD OBJECTIVE:

Tom will decrease contacts with law enforcement for disturbing the peace from 5 times

a week to 2 times a week or less.

Sally will increase attendance at school from 0 days to 3 days per week.

EXAMPLE OF A POOR OBJECTIVE:

“Decrease psychiatric symptoms.” - (The objective lacks specificity, frequency, and

duration related to specific symptoms and is too vague to measure).

Do NOT use percentages (%). They are difficult to track and measure.

Interventions are the therapeutic activities provided by staff to assist the client in attaining the

objective in each goal. In other words, how can staff provide a clinical service to assist the

client to meet his/her goals? There must be at least two interventions per goal provided by

staff members.

T

C

Documentation Tip

DOCUMENTATION TIP

INTERVENTION

CLIENT NAME will INCREASE/DECREASE FUNCTIONAL IMPAIRMENT from BASELINE

Return to Top of Section Return to Table of Contents

19

Interventions may also include what the client or client’s support person is going to do to work

towards the goal (i.e. therapeutic homework, attending a social skills group, wellness group,

etc.).

Interventions must address the objectives and must include duration and frequency. All

services must be included in this section.

One way to capture the required elements of an intervention is to utilize the following

intervention template:

EHR Documentation examples (Section XI) included later in this manual show an

alternative way to capture the required elements for an intervention. These examples show

interventions using the mandatory duration and frequency fields in the MyAvatar client

Treatment Plan.

EXAMPLES OF A GOOD INTERVENTION USING TEMPLATE:

Clinician will provide individual therapy and will use cognitive behavioral techniques

to assist client in reducing symptoms of self-deprecating and suicidal ideation.

(weekly for one year)

Client will attend social skills group to improve social skills by interacting with same

aged peers. (weekly for one year)

Staff will provide rehab services to model and encourage client to practice social

skills. (2 times/week for 6 months)

Clinician will use structured play therapy (stop, think, and listen game) to increase

impulse control skills. (weekly for 3 months)

Medical staff will provide medication education (side effects, medication

efficacy) to support adherence to medications and reduce symptoms. (1 time

every 3 months for one year)

EXAMPLES OF A SUPPORT PERSON INTERVENTION:

Mom will play with Johnny for at least 20 minutes a day for the next six months to

increase his abilities to gain positive attention and encourage bonding

T

C

TYPE OF SERVICE FREQUENCY & DURATION to ACTION WORD FUNCTIONAL IMPAIRMENT

Return to Top of Section Return to Table of Contents

20

Brian’s daughter will drive him to bingo 1x/week for the next 6 months to assist him

to increase socialization and decrease isolation.

Interventions not included in the treatment plan are subject to disallowance; i.e.,

group therapy being provided without listing it as an intervention. Also

interventions that are addressed in the treatment plan and then never utilized may

also be reviewed and should be addressed in a progress note as to why the

intervention is not being provided, if this continues it may indicate needing to

update the treatment plan.

The “Signatures” section indicates the client’s participation and agreement with the

Treatment Plan (CCR Title 9 Division 1, §1810.440).

Treatment planning sessions shall always be documented in a progress note (as plan

development). An excellent progress note contains information about the client and the

client’s significant support person’s participation in the treatment planning process and/or

signing the plan.

The client must be offered a copy of the Treatment Plan and acknowledge our offer of the

copy by signing the plan as the signature states: “Client helped develop, understands,

agrees with the goals, and has been offered a copy of this client plan.”

Signatures are required by the client and/or legal guardian and the LPHA.

The client or his/her legal guardian’s signature is required in the Treatment Plan:

If the client does not or cannot sign the plan, then a progress note shall document

the reason for the missing signature.

Ongoing efforts to obtain client’s missing signature must be made and

documented.

Exception: If the client refuses to sign, then as best as possible, ascertain the

reason. Renegotiate the goal, if that is the reason. If the client agrees with the goal

and the treatment proposed but still refuses to sign the Treatment Plan then

document that fact in the progress note.

Documentation Tip

SIGNATURES

Return to Top of Section Return to Table of Contents

21

A treatment plan without required signatures or date is subject to disallowance. Don’t be

late!

For the Therapeutic Behavioral Services (TBS) treatment plan, the organizational provider shall

create the TBS treatment plan. Please refer to the TBS SECTION of this manual for further

detail.

THERAPEUTIC BEHAVIORAL SERVICES (TBS) IN THE TREATMENT PLAN:

Return to Top of Section Return to Table of Contents

22

Section V. Dual-Diagnosis

Dual-diagnosis services may be provided for clients with both mental health diagnosis

and substance-related diagnosis, when the primary focus of treatment is on the mental health

diagnosis. Primary focus means more than 50% of services provided address the mental health

diagnosis. The goal to address the use of substances (to cope, or reduce mental health symptoms)

must be the secondary goal on the treatment plan. The primary goal on the treatment plan

must address the mental health condition. While dual diagnosis can be treated a majority (50% or

more) of the services provided to the client must be focused on the mental health condition, rather

than on the substance use condition.

Dual-diagnosis services provided by the mental health clinics of the Department of Behavioral

Health must focus on the mental/behavioral health needs of the client. Dealing with

mental/behavioral health concepts and needs is acceptable including how the client:

Recognizes and attempts to meet needs

Deals with emotions

Makes plans

Carries out responsibilities, etc.

Remember if services provided primarily focus on sobriety or dealing with aspects of the

client’s substance use or dependence (whether to use, how much to use, how to quit, etc.),

the services will be subject to audit disallowance.

An objective will address a problem (functional impairment), be observable and/or measurable,

and have a baseline and target. NOTE: the ‘Objective’ in MyAvatar is equivalent to previous

treatment plan “Goal” used in standard treatment plans of the past.

to TARGET

T

C

CLIENT NAME will INCREASE/DECREASE FUNCTIONAL IMPAIRMENT from BASELINE

VI. DUAL DIAGNOSIS

Documentation Tip

FOCUS OF SERVICE

OBJECTIVES

Return to Top of Section Return to Table of Contents

23

An intervention is the therapeutic activity to be taken by staff to assist the client to attain the

goal.

DUAL DIAGNOSIS SAMPLE GOAL (OPIOIDS):

PROBLEM: James uses prescription opioids to numb feelings of pain (emotional and

physical)

GOAL: “I need to stop using (prescription opioids) because it’s causing problems at

home and I have been missing work.

OBJECTIVE: James will decrease opioid use from 3 times per day to one time per day.

INTERVENTIONS:

1. Individual Therapy weekly to assist James in identifying early warning signs, or

triggers, that increase the desire to use opioids over the next 12 months.

2. Rehabilitation services or individual therapy weekly to teach relaxation skills and

coping skills to James to use when relapse triggers occur or when intense emotions

arise (anxiety, anger, fear) to decrease desire to use opioids over the next 12

months.

3. Rehabilitation services or individual therapy monthly to assist James in identifying

the benefits/positive outcomes that result from not using (in marriage, job, with

children) to decrease his use of opioids for the next 12 months.

4. Individual Therapy monthly to teach James to keep a diary of relapse triggers and

how he managed them to reinforce his efforts to stop using opioids for the next 12

months.

DUAL DIAGNOSIS SAMPLE GOAL (CANNABIS):

PROBLEM: Client uses cannabis when he feels anxious.

GOAL: “I want to feel better.”

OBJECTIVE: Client will reduce cannabis use from daily to 3 times a week or less

within 12 months.

ACTION WORD TECHNIQUE to INCREASE/DECREASE FUNCTIONAL IMPAIRMENT

INTERVENTIONS

Return to Top of Section Return to Table of Contents

24 

INTERVENTIONS:  

1. Rehabilitation services and individual therapy weekly for 12 months to assist 

Client in identifying ways he has successfully managed anxiety in the past.  

2. Individual therapy weekly for 12 months to assist client in recognizing triggers to 

anxiety.  

3. Rehabilitation or group rehabilitation weekly for 12 months to educate client 

about the side effects of cannabis and increased anxiety 

4. Rehabilitation or group rehabilitation weekly for 12 months to teach, model, 

and encourage the use of healthy coping techniques 

5. Individual therapy weekly for 12 months to explore both the positive and 

negative consequences of client’s substance use as it relates to anxiety 

6. Brokerage services to refer client to dual diagnosis group if available or other 

needed community resources (12 months). 

Return to Top of Section Return to Table of Contents 

25

1. When a client has either met their goals and can transition to a lower level of care or out

of services a discharge bundle must be completed.

2. The discharge bundle includes a discharge summary as well as a diagnosis option to

record the client’s discharge diagnosis. This bundle can also be utilized when a client

discontinues services without notifying staff and fails to respond to phone calls or

letters offering additional services.

3. Review next section “Documenting by Service Type – Progress Notes” for further

information on Discharge.

VII. DISCHARGE

Return to Top of Section Return to Table of Contents

26

This next section provides guidance on how to document for each service type into a progress

note. Each section is organized with an overview of the function of the service type then shows

the billable activities associated with that service type. Examples are included along with tips

for writing a progress note to capture each service type.

Progress notes are a summary description of what was accomplished or attempted at the time

the service activity was delivered that assisted the client to make progress towards goals. The

key word is “progress.” In general, progress means “to advance or make steady increases

towards a goal.”

Progress notes should be written objectively. Refrain from using negative language about

clients. Remember that a client can request his/her chart at any time, or a court may subpoena

a chart.

1. Every service activity must have a separate, corresponding note (i.e. if you provided two

different services to the same client in the same day, each service requires a separate note).

2. All progress notes need to include the following items:

a. Date of each service

b. Duration of service in exact minutes

i. Documentation/Travel time

c. The Treatment Plan objective being charted to

d. The clinical intervention(s)

e. Client’s clinical response to the intervention

f. Plan for continued treatment

i. Record any therapeutic assignments (homework) for the time between

sessions

T

C

DOCUMENTING BY SERVICE TYPE – PROGRESS NOTES

PROGRESS NOTES

GENERAL RULES FOR PROGRESS NOTES

1.

2.

VIII. PROGRESS NOTES

Return to Top of Section Return to Table of Contents

27

g. Must be legible

h. Notes entered by DragonSpeak/transcription program must be proofread prior to

final submission into EHR

i. Service provider’s handwritten or approved electronic signature

i. Signatures must include: staff’s professional degree, license or job title

ii. Signatures must be legible or accompanied by a printed name

3. Every service is expected to be documented in a timely manner. All staff are encouraged to use concurrent documentation (write your note with the client present) to write notes in real time, eliminate post service documentation time, and increase the client’s involvement in his or her clinical record.

When more than one staff member participates in a service for the same client, each staff must write a note for the time they were present and billed for the service. For example: if two staff participate in a plan development meeting with a client, each staff member writes his/her own note to represent their contribution to the meeting.

CAUTION: We cannot write notes that simply state “See other staff member’s progress note” and must write a note for each service delivered. The only EXCEPTION to this is group notes which allow co-practitioner time to be entered. (Group notes operate differently than other progress notes).

4. BCDBH requires the use of the D.I.R.T. format for the following service types:

Assessment, Rehabilitation, Therapy, Collateral, Crisis Intervention, Intensive Care

Coordination, Intensive Home Based Services and Therapeutic Behavioral Services.

DESCRIBE the presenting problem, how the client presents him/herself, or the

reason for the service activity.

INTERVENTION What treatment plan service was provided by the clinician?

RESPONSE What was the client’s clinical response to the intervention?

TREATMENT PLAN What is the next step for the recovery process?

T

C

I

T

D

R

4.

5.

!

3.

Return to Top of Section Return to Table of Contents

28

6. Refer to SECTION XI (Documentation Examples) for examples of notes by service type and

to view notes that contain all the required elements. View APPENDIX D for Progress Note

Formatting Guidelines.

If client has a recent history of suicidal or homicidal ideation and/or hospitalization,

document potential risk in each progress note

“Assessment” means a service activity designed to evaluate the current status of a

beneficiary’s mental, emotional, or behavioral health. Assessment includes but is not limited to

one or more of the following: mental status determination, analysis of the beneficiary’s clinical

history; analysis of relevant cultural issues and history; diagnosis; and the use of testing

procedures (CCR Title 9 Division 1, §1810.204) (For information on how to complete an

assessment document or option, please refer to the Assessment section).

ACTIVITIES Assessment activities are usually face-to-face or by telephone with or without the client or

significant support persons and may be provided in the office or in the community. An

assessment may also include gathering information from other professionals.

Examples include the following:

Interviewing the client and/or significant support persons to obtain information to

assist in providing focused treatment.

Administering, scoring, and analyzing psychological tests and outcome measures such

as FIT, CANS and the MORS.

In some instances, gathering information from other professionals (e.g., teachers,

previous providers, etc.) and reviewing/analyzing clinical documents/ other relevant

documents may be justified as contributing toward the assessment.

Observing the client in a setting such as milieu, school, etc. may be indicated for clinical

purposes.

PROGRESS NOTE- ASSESSMENT

Each assessment activity requires a progress note. The note should contain a brief

summary of what was completed during the assessment interview/session, who was

Documentation Tip

MENTAL HEALTH SERVICES – ASSESSMENT (3310)

6.

Return to Top of Section Return to Table of Contents

29

present/participated in the service delivery, and record the exact time the assessment

service lasted.

The final assessment progress note date should match the date the assessment is

finalized in the EHR. An additional progress note shall be written if an assessment is

appended or updated.

CAUTION: – A diagnosis can only be provided to a client after the clinician has met with

him/her face-to-face.

“Plan Development” means a service activity which consists of development of client plans,

approval of client plans, and/or monitoring of a beneficiary’s progress related to the client plan.

(CCR Title 9 Division 1, §1810.232) Client plans drive services and are based on the assessment.

ACTIVITIES

Plan Development activities may be face-to-face or by telephone with the client or

significant support persons and may be provided in the office or in the community. Plan

Development may also include contact with other professionals.

Plan development activities can be conducted with or without the client, and include the

five following items:

Development of the treatment plan

Approval of the treatment plan

Updating of the treatment plan

Monitoring the client’s progress in relation to the treatment plan

Discharge planning

PROGRESS NOTES

Plan Development progress notes are expected to refer to the treatment plan (i.e.

development, approval, updating, or monitoring and/or discussing updating the client’s

diagnosis)

Discharge summaries document the termination and/or transition of services, and

provide closure for a service episode and referrals as appropriate

MENTAL HEALTH SERVICES – PLAN DEVELOPMENT (3910)

!

Return to Top of Section Return to Table of Contents

30

Administrative tasks such as “closing out the chart," “copying,” or “filing” cannot be

claimed as billable services.

MISCELLANEOUS

Plan Development may be provided during the development/approval of the initial

Treatment Plan and subsequent Treatment Plans. However, Plan Development can be

provided at other times, as clinically indicated. For example, the client’s status changes

(i.e. significant improvement or decline) and there may be a need to update the

Treatment Plan.

Plan Development may include activities without the client’s presence, such as

collaborating with other professionals in the development, monitoring progress or

updating of the Treatment Plan.

Multiple Plan Development service activities for one event are at risk of disallowance, if

inappropriately documented. For example, if several staff members are present at a

treatment team meeting in which a client’s Treatment Plan is discussed, the only staff

that can bill are those who are actively involved in that client’s treatment, i.e. client’s

doctor and therapist.

Supervision, individual or group, is never a bill-able activity.

“Collateral” means a service activity to a significant support person in a beneficiary’s life for the

purpose of meeting the needs of the beneficiary in terms of achieving the goals of the

beneficiary’s client plan. Collateral may include but is not limited to: consultation and training

of the significant support person(s) to assist in better utilization of specialty mental health

services by the beneficiary, consultation and training of the significant support person(s) to

assist in better understanding of mental illness, and family counseling with the significant

support person(s). The beneficiary may or may not be present for this service activity. (CCR

Title 9 Division 1, 1810.206).

DOCUMENTATION TIP

MENTAL HEALTH SERVICES – COLLATERAL (3110)

Documentation Tip

Return to Top of Section Return to Table of Contents

31

ACTIVITIES

Collateral activities are usually face-to-face or by telephone with the significant support

person, and may be provided in the office or in the community. The client may or may not

be present.

Examples include the following:

Educating the support person about the client’s mental illness

Training the support person to better support or work with the client

PROGRESS NOTES

Collateral progress notes must include the staff intervention(s) identified on the client

plan (e.g., educating, training, etc.) and must demonstrate how they benefit the client

Collateral progress notes should include the role of the significant support person (e.g.

parent, guardian, etc.)

Documentation should substantiate that the support person is significant in the client’s

life

An excellent collateral progress note should document the changes that occurred as a

result of educating and training the significant other, e.g., show how parents learned

and demonstrated new ways of dealing with their child’s symptoms or behaviors.

If you are working with a significant other as a collateral service, documentation must

include how the clinician educated or trained the significant other to better understand

or support the client.

Collateral groups (i.e., parenting groups) are billable with or without the client. The

note must reflect how the interventions benefit the client.

“Rehabilitation” means a service activity which includes, but is not limited to assistance in

improving, maintaining, or restoring a beneficiary’s or group of beneficiaries’ functional

skills, daily living skills, social and leisure skills, grooming and personal hygiene skills, meal

preparation skills, and support resources; and /or medication education. (CCR Title 9 Division 1,

1810.243) It is important to distinguish “rehabilitation” versus “personal care activities.”

Personal care activities are not reimbursable activities. The following graphic shows the

distinction between rehabilitation and personal care activities:

T

C

MENTAL HEALTH SERVICES – REHABILITATION (3450)

Return to Top of Section Return to Table of Contents

32

It should be noted that Rehabilitative Activities are designed to enable the client to

overcome the limitations due to the mental disorder and to teach the client to

function in an age appropriate manner without the need for redirection or

intervention.

ACTIVITIES

Rehabilitation activities are usually face-to-face or by telephone with the client and may be

provided in the office or in the community. Rehabilitation can be done as:

Individual Rehabilitation

Group Rehabilitation (for two or more clients)

Education, training, and counseling to the client in relation to the four following

functional skills:

1. Health – medication education and compliance, grooming and personal hygiene

skills, meal preparation skills

2. Daily Activities – money management, leisure skills

3. Social Relationships – social skills, developing and maintaining a support system

4. Living Arrangement – maintaining current housing situation

PROGRESS NOTES – GROUP REHABILITATION (3570)

When providing Group Rehabilitation (i.e. two or more clients), the progress note must

include the following four items, otherwise it is at risk of disallowance:

T

C

REHABILITATION PERSONAL CARE ACTIVITIES VS

Enable client to overcome limitations due to mental disorder

Performing activities for the client who is unable to do for themselves

Feeding client; preparing meals for client; general care

EXAMPLE

Teaching client to prepare his/her meals

EXAMPLE

DOCUMENTATION TIP

Return to Top of Section Return to Table of Contents

33

1. Type or name of group

2. Total group time, which is the time spent in group plus documentation time and may

also include travel time

o Duration of service in exact minutes

Start and Stop times of the direct service

Documentation/Travel time

3. Number of clients

4. Number of staff and their names (if there is more than one staff member) with

appropriate credentials

If there are two staff members co-facilitating a group, document the need for more than

one facilitator.

Progress notes that fail to provide adequate information about the intervention(s) are at

risk of disallowance because it may be unclear if the ‘Rehabilitation Activity’ was provided.

“Therapy” means a service activity which is a therapeutic intervention that focuses primarily on

symptom reduction as a means to improve functional impairments. Therapy may be delivered

to an individual or group of beneficiaries and may include family therapy at which the

beneficiary is present. (CCR Title 9 Division 1, 1810.250)

For documentation of a therapy note, the interventions must focus on amelioration or

reduction of mental health symptoms.

ACTIVITIES

Therapy can be face-to-face, or over the telephone, or via telemedicine with the client(s) or

family, and may be provided in the office or in the community.

Individual Therapy

Group Therapy (for two or more clients)

Family Therapy with the client present

T

C

DOCUMENTATION TIP

MENTAL HEALTH SERVICES – THERAPY (3410, 3412, 3414, 3415)

Return to Top of Section Return to Table of Contents

34

Therapy can only be provided by an LPHA or a trainee supervised by an LPHA. See the

Scope of Practice section for more information.

PROGRESS NOTES – GROUP THERAPY (3510)

When providing Group Therapy (i.e., two or more clients), the progress note must include

the following four items, otherwise it is at risk of disallowance:

1. Type or name of group

2. Total group time, which is the time spent in group plus documentation time and

may also include travel time

o Duration of service in exact minutes

Documentation/Travel time

3. Number of clients

4. Number of clinicians, their names (if there is more than one clinician) with

appropriate credentials, and their time spent providing the group service

If there are two clinicians co-facilitating a group, document the need for more than one

facilitator.

Progress notes that fail to provide adequate information about the intervention(s)

are at risk of disallowance because it may be unclear if the Therapy activity was

provided; i.e., each note must have the problem area/clinical focus, staff

intervention and the client’s response. Each note must be unique to the client as

well as to an intervention on their client plan.

Targeted Case Management (TCM) – Linkage and Brokerage service includes a broad array of

services designed to assist and support clients, including life areas that fall outside of the

mental health system.

Definition of TCM – Linkage and Brokerage services are services that assist a beneficiary to

access needed medical, educational, social, prevocational, vocational, rehabilitative, or other

community services. The service activities may include, but are not limited to, communication,

coordination, and referral; monitoring service delivery to ensure beneficiary access to service

DOCUMENTATION TIP

DOCUMENTATION TIP

TARGETED CASE MANAGEMENT (3030)

Return to Top of Section Return to Table of Contents

35

and the service delivery system; monitoring of the beneficiary’s progress; placement services;

and plan development (CCR Title 9 Division 1, 1810.249).

Linkage and Brokerage – Assist clients to access and maintain needed services such

as psychiatric, medical, educational, social, prevocational, vocational, rehabilitative,

or other community services

Placement – Assist clients to obtain and maintain adequate and appropriate living

arrangements

Consultation – Exchange of information with others in support of client’s services

ACTIVITIES

TCM - Linkage and Brokerage activities are usually face-to-face or by telephone with the

client or significant support persons and may be provided in the office or in the community.

These services may also include contact with other professionals.

Communicating, consulting, coordinating and corresponding with the client and/or

others to establish the need for services and a plan for accessing these services

Establishing and making referrals

Monitoring the client’s access to services

Monitoring the client’s progress once access to services has been established

Locating and securing an appropriate living arrangement, including linkage to

resources; i.e., Board and Care, Section 8 Housing, or transitional living

Arranging and conducting pre-placement visits, including negotiating housing or

placement contracts

Case management does not include transportation solely for the purpose of transportation….or

waiting for a doctor’s appointment, waiting at SSI office, completing SSI paperwork….

PROGRESS NOTES

A TCM Linkage and Brokerage progress note includes the focus of the

assistance/intervention provided to the client (e.g., accessing medical services) and justifies

the need for this service based on mental health symptoms/issues; i.e. who was spoken to,

what was discussed with professional, what is the plan, is there a referral to an outside

service and what is the next step needed to assist the client.

MISCELLANEOUS

See Lock-Out Grid APPENDIX E

DOCUMENTATION TIP

Return to Top of Section Return to Table of Contents

36

Crisis Intervention is an immediate emergency response that is intended to help the client cope

with a crisis (e.g. potential danger to self or others; potentially life altering event; severe

reaction that is above the client’s normal baseline, etc.).

Definition – “Crisis Intervention” means a service, lasting less than 24 hours, to or on behalf of

a beneficiary for a condition that requires more timely response than a regularly scheduled

visit. Crisis Intervention is distinguished from Crisis Stabilization by being delivered by

providers who do not meet the Crisis Stabilization contact, site, and staffing requirements

described in Sections 1840.338 and 1840.348. (CCR Title 9 Division 1, 1810.209)

ACTIVITIES

Crisis Intervention activities are usually face-to-face or by telephone with the client or

significant support persons and may be provided in the office or in the community. These

include:

Assessment of the client’s mental status, acuity of symptoms and current need

Therapeutic services for the client

Education, training, counseling, or therapy for significant support persons involved

PROGRESS NOTES

An excellent Crisis Intervention progress note contains a clear description of the “crisis,” in

order to distinguish the situation from a more routine event and the interventions used to

help stabilize the client.

All services provided (i.e., Crisis Assessment, safety plan, Collateral, Individual/Family

Therapy, TCM - Linkage and Brokerage) shall be billed as Crisis Intervention.

Once the crisis is resolved, any follow-up cannot be billed as Crisis

The maximum amount claimable to Medi–Cal for crisis intervention in a 24-hour

period is 8 hours (480 minutes) per client

Two people cannot bill crisis simultaneously on one client when the purpose of the

presence of the other staff member is purely for safety reasons.

MENTAL HEALTH SERVICES – CRISIS INTERVENTION (3710/3715)

DOCUMENTATION TIP

Return to Top of Section Return to Table of Contents

37

“Medication Support Services” means those services that include prescribing, administering,

dispensing and monitoring of psychiatric medications or biologicals that are necessary to

alleviate the symptoms of mental illness. Service activities may include but are not limited to

evaluation of the need for medication; evaluation of clinical effectiveness and side effects; the

obtaining of informed consent; instruction in the use, risks and benefits of and alternatives for

medication; and collateral and plan development related to development related to the

delivery of the service and/or assessment of the beneficiary (CCR Title 9 Division 1, 1810.225).

CAUTION: These symptoms should be related to the client’s documented diagnosis.

ACTIVITIES

Medication Support Services activities are usually face-to-face or by telephone with the

client or significant support persons and may be provided in the office or in the community.

These services include:

Evaluation of the need for psychiatric medication

Evaluation of clinical effectiveness and side effects of psychiatric medication

Medication education, including discussing risks, benefits and alternatives with the

client or support persons

Ongoing monitoring of the client’s progress in relation to the psychiatric medication

Prescribing, dispensing, and administering of psychiatric medications

The maximum amount claimable to Medi-Cal for medication support services in a

24-hour period is 4 hours (240 minutes) per client

Intensive Care Coordination services are provided to Katie A. “Subclass” members that are

similar to the types of services provided with Linkage and Brokerage services. The difference

between ICC and the more traditional Linkage and Brokerage services is that ICC must be used

to facilitate the implementation of the cross-system/multi-agency collaborative services

approach described in the Core Practice Model Guide for Katie A Subclass. ICC service

components and activities are:

MEDICATION SUPPORT SERVICES

!

KATIE A SUBCLASS - MENTAL HEALTH SERVICES – INTENSIVE CARE COORDINATION

(3040)

SPECIAL POPULATIONS – PROGRESS NOTES

Return to Top of Section Return to Table of Contents

38

Assessing

Assessing client’s and family’s needs and strengths

Assessing the adequacy and availability of resources

Reviewing information from family and other sources

Evaluating effectiveness of previous interventions and activities

2. Service Planning and Implementation

Developing a plan with specific goals, activities, and objectives

Ensuring the active participation of client and individuals involved and clarifying

the roles of individuals involved

Identifying the interventions/course of action targeted at the client’s and

family’s assessed goals

3. Monitoring and Adapting

Monitoring to ensure that identified services and activities are progressing

appropriately

Changing and redirecting actions targeted at the client’s and family’s assessed

needs, not less than every 90 days

4. Transition

Developing a transition plan for the client and family to foster long term stability

including the effective use of natural supports and community resources

Medi-Cal Manual for Intensive Care Coordination (ICC), Intensive Home-based

Services (IHBS) & Therapeutic Foster Care (TFC) for Katie A. Subclass Members

Pathways to Mental Health Services – Core Practice Model (CPM) Guide

Intensive Home-Based Services (IHBS) are intensive, individualized and strength-based, needs-

driven intervention activities that support the engagement and participation of a child/youth

and his/her significant support persons and to help the child/youth develop skills and achieve

the goals and objectives of the client plan. IHBS are not traditional therapeutic services. This

service is targeted to the Katie A. Subclass (and their significant support persons). Services are

expected to be of significant intensity to address the intensive mental health needs of the

child/youth, consistent with the client plan and the Core Practice Model. Services may be

WEB

DELL

WEB

DELL

LINK

DELL

KATIE A SUBCLASS – MENTAL HEALTH SERVICES – INTENSIVE HOME-BASED SERVICES (3230)

2.

1.

3.

4.

Return to Top of Section Return to Table of Contents

39

delivered in the community, school, home or office settings. IHBS services includes, but not

limited to:

Medically necessary skill-based interventions for the remediation of behaviors or

improvement of symptoms

Development of functional skills to improve self-regulation or self-care

Education of the child/youth/family/caregiver about how to manage the clients’

symptoms

Support of the development, maintenance and use of social networks and community

resources

Support to address behaviors that interfere with the achievement of a stable and

permanent family life and stable housing, obtain and maintain employment and

achieving educational objectives

Therapeutic Behavioral Services (TBS) are supplemental specialty mental health services under

the EPSDT benefit. TBS is an intensive, individualized, one to one, short-term, outpatient

treatment intervention for clients up to age 21 with Serious Emotional Disturbances (SED) who

are experiencing a stressful transition or life crisis that is placing the individual at risk of an out

of home placement in a RCL 12 or higher or are at risk of a psychiatric emergency. TBS is also

used to help a client transition from this high level of care (RCL 12 group home or psychiatric

hospital to a lower level of care.

ACTIVITIES

TBS activities are usually face-to-face with the client and can be provided in most settings.

TBS-related activities can also be provided to significant support persons in collaboration

with other professionals.

One-to-one therapeutic contact typically models/teaches, trains or supports

appropriate behavioral changes

TBS activities may also include assessment, collateral, and plan development,

which are coded as TBS

TBS is provided only by qualified providers (see Scope of Practice grid)

MENTAL HEALTH SERVICES – THERAPEUTIC BEHAVIORAL SERVICES (3230)

Return to Top of Section Return to Table of Contents

40

Reference the California Department of Mental Health’s October 2009 TBS

Documentation Manual for additional information. See web link below:

DHCS Therapeutic Behavioral Services Website

MEDICATION EVALUATION

For Prescribers only:

This service is used when a psychiatric assessment is performed by a Prescriber

MEDICATION MANAGEMENT

For Prescribers only:

Includes clinic visits, refilling prescriptions, face-to-face or telephone consults

with other Medical Prescribers

MEDICATION SUPPORT NON- PRESCRIBERS

For Medical Staff Non- Prescribers (Registered Nurses, Licensed Vocational Nurses &

Licensed Psychiatric Technicians)

Administering of medication per Prescriber’s orders

Evaluation of clinical effectiveness and side effects of psychiatric medication

Ongoing monitoring of the client’s progress in relation to the psychiatric

medication

Medication education, including discussing risks, benefits and alternatives with

the client or support persons

PSYCHIATRIST, PRESCRIBERS AND ALL MEDICAL STAFF NON- PRESCRIBERS (see

above) CAN ALSO PROVIDE:

Medication Injection

Prep report other Physicians/Agency (Preparation of report for other

physicians/agencies)

Review Hospital Records/Reports/Labs (Review of hospital records, reports and

labs)

CAUTION: Aside from Medication Support Services, all medical staff may also provide Plan

Development, TCM-Linkage and Brokerage or Crisis Intervention as needed.

SERVICES & DESCRIPTIONS PERTAINING TO MEDICAL STAFF

4.

1.

2.

3.

!

DOCUMENTATION TIP

WEB

DELL

LINK

DELL

Return to Top of Section Return to Table of Contents

41

VII. Non-Reimbursable Services

For Medi-Cal, some services are not eligible for reimbursement, even though they may

be provided on behalf (and to the benefit) of the client. These non-reimbursable services

include, but are not limited to, the following:

Academic educational services

Vocational services which have as a purpose actual work or work training

Recreation

Personal care services provided to clients (e.g. grooming, personal hygiene, assisting

with medication, preparation of meals, etc.)

Socialization if it consists of generalized group activities which do not provide

systematic individualized feedback to the specific target behaviors of the clients

involved

Transportation of a client

Service provided solely payee related

Translation/interpretation services

Missed appointments

Travel time when no face-to-face contact with the client or significant support person

was provided, including leaving a note on the door for the client

Leaving and/or listening to telephone messages

Communication via e-mail unless clinically appropriate (e.g., therapeutic

communication for deaf and hard-of-hearing clients)

Completing mandatory reports: CSD, APS, Tarasoff, etc., including making associated

phone calls

Completing Social Security reports

Clerical tasks: faxing, copying, mailing, etc.

After the death of a client, no services are billable

Supervision in which the primary purpose is for the benefit of the clinician, which

includes trainees and student interns. Regularly scheduled supervision time would not

be reimbursable, even though the client’s care may be discussed.

IX. NON-REIMBURSABLE SERVICES $

Return to Top of Section Return to Table of Contents

42

Staff development activities, including conferences, workshops, trainings, reading

literature, Internet searches, etc.

Preparation for a service activity, such as collecting materials for a group session

Cleaning the office/play therapy room after client leaves

While the above services are non-billable, some of these activities should be documented

using the 4010 informational note code or 4000 no show code.

DOCUMENTATION TIP

Return to Top of Section Return to Table of Contents

43

(See ‘Lock–Out Grid’ in APPENDIX E)

A “lockout” means that a service activity is not reimbursable through Medi-Cal because the

client resides in and/or receives mental health services in one of the settings listed below. A

clinician may provide the service (e.g. targeted case management for a client residing in an

IMD), but it would be reimbursable only under certain circumstances – See Lock–Out Grid in

APPENDIX E.

Jail/Prison

Juvenile Hall (not adjudicated)

Institute of Mental Disease (IMD)

No service activities are reimbursable if the client resides in one of these settings (except for

the day of admission & discharge):

Psychiatric Inpatient

Psychiatric Nursing Facility

Exception: Medication Support Services or TCM-Linkage and Brokerage (for placement

purposes only within 30 days of discharge) are reimbursable

No other service activities are reimbursable if the client resides in one of these settings (except

for the day of admission & discharge):

Crisis Stabilization

No other service activities are reimbursable during the same time period that the client is at

the Crisis Stabilization Unit (Except for the day of admission and discharge, before or after).

Exception: Targeted Case Management for placement purposes only is reimbursable

while client is at the Crisis Stabilization Unit

INTENSIVE CARE COORDINATION

For members of the target group who are transitioning to a community setting ICC

services will be made available for up to 30 calendar days for a maximum of three non-

consecutive periods of 30 calendar days 25 or less per hospitalization or inpatient stay

prior to the discharge of a covered stay in a medical institution. The target group does

X. LOCK–OUTS

Return to Top of Section Return to Table of Contents

44

not include individuals between ages 22 and 64 who are served in an IMD or individuals

who are inmates of public institutions. ICC may be provided solely for the purpose of

coordinating placement of the child/youth on discharge from the hospital, psychiatric

health facility, group home or psychiatric nursing facility, may be provided during the

30 calendar days immediately prior to the day of discharge, for a maximum of three

nonconsecutive periods of 30 calendar days or less per continuous stay in the facility as

part of discharge planning.

INTENSIVE HOME-BASED SERVICES

Mental health services (including IHBS) are not reimbursable when provided by day

treatment intensive or day rehabilitation staff during the same time period that day

treatment intensive or day rehabilitation services are being provided. Authorization is

required for mental health services if these services are provided on the same day that

day treatment intensive or day rehabilitation services are provided. IHBS may not be

provided to children/youth in Group Homes. IHBS can be provided to children/youth

that are transitioning to a permanent home environment to facilitate the transition

during single day and multiple day visits outside the Group Home setting. Certain

services may be part of the child/youth’s course of treatment, but may not be provided

during the same hours of the day that IHBS services are being provided to the

child/youth. These services include:

Day Treatment Rehabilitative or Day Treatment Intensive

Group Therapy

Therapeutic Behavioral Services (TBS)

Targeted Case Management (TCM)

Standard Skilled Nursing Facility (SNF) is NOT a lock-out environment; only a

Skilled Psychiatric Nursing Facility would be a lock-out. A Skilled Nursing

Psych Facility requires more than 50% of the beds to be “psych” beds.

DOCUMENTATION TIP

Return to Top of Section Return to Table of Contents

45 

 

  Each of these documents will provide an example for how to properly fill out various forms 

related to the previous sections. All individuals highlighted in these following examples are fictitious 

and have been created for the sole purpose of providing examples. There are 2 sections of examples: 

adult examples and youth examples. Examples will be listed in the order they appear in the list below. 

Each title is clickable and will take you to the desired documentation example. If you want to return 

from the documentation example to the adult or youth lists below, click the small banner next to the 

name of the example. 

 

INFORMED CONSENT 

NOTICE OF PRIVACY PRACTICES 

GUIDE TO MEDI‐CAL MENTAL HEALTH SERVICES 

INITIAL ASSESSMENT 

MENTAL STATUS EXAM 

MEDICAL NECESSITY DETERMINATION 

DIAGNOSIS REPORT  

TREATMENT (TX) PLAN 

PROGRESS NOTE – ASSESSMENT(3310) 

PROGRESS NOTE – CRISIS(3715) 

PROGRESS NOTE – REHABILITATION(3450) 

PROGRESS NOTE – BROKERAGE MEDICAL APPOINTMENT(3030) 

PROGRESS NOTE – MEDICAL(3630) 

PROGRESS NOTE – BROKERAGE PHONE CALL(3030) 

PROGRESS NOTE – PLAN DEVELOPMENT(3910) 

PROGRESS NOTE – REHABILITATION GROUP(3570) 

DISCHARGE DIAGNOSIS 

DISCHARGE REPORT 

     XI. DOCUMENTATION EXAMPLES 

ADULT EXAMPLES 

Return to Top of Section Return to Table of Contents 

46 

 

INFORMED CONSENT 

NOTICE OF PRIVACY PRACTICES 

GUIDE TO MEDI‐CAL MENTAL HEALTH SERVICES 

INITIAL ASSESSMENT 

MENTAL STATUS EXAM 

DIAGNOSIS REPORT 

MEDICAL NECESSITY DETERMINATION 

YOUTH TREATMENT (TX) PLAN 

PROGRESS NOTES – ASSESSMENT(3310)  

PROGRESS NOTES – PLAN DEVELOPMENT(3910) 

PROGRESS NOTES – INDIVIDUAL(3412) 

PROGRESS NOTES – COLLATERAL(3110) 

PROGRESS NOTES – REHABILIATION(3450) 

PROGRESS NOTES – PLAN DEVELOPMENT(3910) 

PROGRESS NOTES – INFORMATIONAL NOTE(4010) 

PROGRESS NOTES – BROKERAGE(3030) 

PROGRESS NOTES – COLLATERAL(3110) 

PROGRESS NOTES – COLLATERAL GROUP(3112) 

PROGRESS NOTES – KATIE A – INTENSIVE CARE COORDINATION(3040) 

PROGRESS NOTES – KATIE A – INTENSIVE HOME BASED SERVICES(3420) 

YOUTH EXAMPLES 

Return to Top of Section Return to Table of Contents 

47

ADULT INFORMED CONSENT Adult Examples List

Return to Top of Section Return to Table of Contents

48

ADULT NOTICE OF PRIVACY PRACTICES Adult Examples List

Return to Top of Section Return to Table of Contents

49

ADULT GUIDE TO MEDI-CAL MENTAL HEALTH SERVICES Adult Examples List

Return to Top of Section Return to Table of Contents

50

ADULT INITIAL ASSESSMENT Adult Examples List

Return to Top of Section Return to Table of Contents

51 Return to Top of Section Return to Table of Contents

52 Return to Top of Section Return to Table of Contents

53

ADULT MENTAL HEALTH STATUS EXAM Adult Examples List

Return to Top of Section Return to Table of Contents

54 Return to Top of Section Return to Table of Contents

55

ADULT MEDICAL NECESSITY DETERMINATION Adult Examples List

Return to Top of Section Return to Table of Contents

56 Return to Top of Section Return to Table of Contents

57 Return to Top of Section Return to Table of Contents

58 Return to Top of Section Return to Table of Contents

59

ADULT DIAGNOSIS REPORT Adult Examples List

Return to Top of Section Return to Table of Contents

60

ADULT DIAGNOSIS REPORT – EXAMPLE 2

Return to Top of Section Return to Table of Contents

61 

ADULT TREATMENT (TX) PLAN  Adult Examples List 

Return to Top of Section Return to Table of Contents 

62 Return to Top of Section Return to Table of Contents 

63 Return to Top of Section Return to Table of Contents 

64

ADULT PROGRESS NOTE – ASSESSMENT Adult Examples List

Return to Top of Section Return to Table of Contents

65

ADULT PROGRESS NOTE – CRISIS Adult Examples List

Return to Top of Section Return to Table of Contents

66

ADULT PROGRESS NOTE – REHABILITATION Adult Examples List

Return to Top of Section Return to Table of Contents

67 Return to Top of Section Return to Table of Contents

68

ADULT PROGRESS NOTE – BROKERAGE MED APPT Adult Examples List

Return to Top of Section Return to Table of Contents

69

ADULT PROGRESS NOTE – MEDICAL PROGRESS NOTE Adult Examples List

Return to Top of Section Return to Table of Contents

70

ADULT PROGRESS NOTE – BROKERAGE PHONE CALL Adult Examples List

Return to Top of Section Return to Table of Contents

71 Return to Top of Section Return to Table of Contents

72

Return to Top of Section Return to Table of Contents

ADULT PROGRESS NOTE – PLAN DEVELOPMENT Adult Examples List

73

Return to Top of Section Return to Table of Contents

74

ADULT PROGRESS NOTE – REHABILITATION GROUP Adult Examples List

Return to Top of Section Return to Table of Contents

75

ADULT PROGRESS NOTE – PLAN DEVELOPMENT Adult Examples List

Return to Top of Section Return to Table of Contents

76

ADULT DISCHARGE DIAGNOSIS Adult Examples List

Return to Top of Section Return to Table of Contents

77 Return to Top of Section Return to Table of Contents

78

ADULT DISCHARGE REPORT Adult Examples List

Return to Top of Section Return to Table of Contents

79 Return to Top of Section Return to Table of Contents

80

YOUTH INFORMED CONSENT Youth Examples List

Return to Top of Section Return to Table of Contents

81

YOUTH NOTICE OF PRIVACY PRACTICES Youth Examples List

Return to Top of Section Return to Table of Contents

82

YOUTH GUIDE TO MEDI-CAL MENTAL HEALTH SERVICES

Return to Top of Section Return to Table of Contents

Youth Examples List

83

YOUTH MENTAL STATUS EXAM

Return to Top of Section Return to Table of Contents

Youth Examples List

84 Return to Top of Section Return to Table of Contents

85

YOUTH INITIAL ASSESSMENT

Return to Top of Section Return to Table of Contents

Youth Examples List

86 Return to Top of Section Return to Table of Contents

87 Return to Top of Section Return to Table of Contents

88

Return to Top of Section Return to Table of Contents

89

YOUTH DIAGNOSIS REPORT

Return to Top of Section Return to Table of Contents

Youth Examples List

90 Return to Top of Section Return to Table of Contents

91

YOUTH MEDICAL NECESSITY DETERMINATION

Return to Top of Section Return to Table of Contents

Youth Examples List

92 Return to Top of Section Return to Table of Contents

93

Return to Top of Section Return to Table of Contents

94 Return to Top of Section Return to Table of Contents

95 

 

YOUTH TREATMENT (TX) PLAN 

Return to Top of Section Return to Table of Contents Return to Top of Section Return to Table of Contents 

Youth Examples List 

96 Return to Top of Section Return to Table of Contents 

97 Return to Top of Section Return to Table of Contents 

98 Return to Top of Section Return to Table of Contents

YOUTH PROGRESS NOTES – ASSESSMENT 3310 Youth Examples List

99

YOUTH PROGRESS NOTES – PLAN DEVELOPMENT 3910 Youth Examples List

Return to Top of Section Return to Table of Contents

100

YOUTH PROGRESS NOTES – INDIVIDUAL 3412 Youth Examples List

Return to Top of Section Return to Table of Contents

101 Return to Top of Section Return to Table of Contents

102

YOUTH PROGRESS NOTES – COLLATERAL 3110 Youth Examples List

Return to Top of Section Return to Table of Contents

103 Return to Top of Section Return to Table of Contents

104

YOUTH PROGRESS NOTES – REHABILITATION 3450 Youth Examples List

Return to Top of Section Return to Table of Contents

105 Return to Top of Section Return to Table of Contents

106

YOUTH PROGRESS NOTES – PLAN DEVELOPMENT 3910 Youth Examples List

Return to Top of Section Return to Table of Contents

107

YOUTH PROGRESS NOTES – INFO NOTE 4010 Youth Examples List

Return to Top of Section Return to Table of Contents

108

YOUTH PROGRESS NOTES – BROKERAGE 3030 Youth Examples List

Return to Top of Section Return to Table of Contents

109 Return to Top of Section Return to Table of Contents

110

YOUTH PROGRESS NOTES – COLLATERAL 3110 Youth Examples List

Return to Top of Section Return to Table of Contents

111 Return to Top of Section Return to Table of Contents

112

YOUTH PROGRESS NOTES – COLLATERAL GROUP 3112 Youth Examples List

Return to Top of Section Return to Table of Contents

113 Return to Top of Section Return to Table of Contents

114

KATIE A – INTENSIVE CARE COORDINATION 3040 Youth Examples List

Return to Top of Section Return to Table of Contents

115 Return to Top of Section Return to Table of Contents

116

KATIE A – INTENSIVE HOME BASED SERVICES 3420 Youth Examples List

Return to Top of Section Return to Table of Contents

117 Return to Top of Section Return to Table of Contents

118

LPHA

“Licensed Practitioner of the Healing Arts (LPHA)” – In Butte County the following are

considered LPHA’s: physicians, licensed/waivered psychologists, licensed/waivered clinical

social workers, licensed/waivered marriage & family therapists, and licensed psychiatric nurse

practitioner.

PRESCRIBER

A prescriber is someone who holds a license that allows them to prescribe medication. In Butte

County, we have MD’s, DO’s, and NP’s who are prescribers. In situations where a client is

receiving mental health and medication services a prescriber’s signature must be on the

treatment plan.

PULLED FORWARD

In the EHR, documents have been designed so that when a client is opened to a new program

staff can “pull forward” information from a previous program, rather than having to manually

enter the information. “Pulled Forward” essentially means to “copy” information into the new

program. This should only be done when a client is transferring from one program to another

and the documentation remains valid. If a document is pulled forward, the person pulling the

document forward must attest that they are pulling it forward and not making any changes. If

changes are needed to a document, the provider must complete a new document.

SCOPE OF PRACTICE

The definition of scope of practice provided by law delineates what the profession does and

places limits upon or confines the breadth of functions persons within a profession may

lawfully perform. Scope of practice in Butte County’s Mental Health Plan also incorporates job

classification. For example, a staff member in a Behavioral Health Counselor (BHC) position

may hold a Master’s Degree in Psychology or Social Work, which technically allows them to

diagnose a client; however, diagnosing is not a function within the BHC job classification and

therefore is not within the scope of practice for a BHC.

VALID

In the context of this documentation manual, valid refers to the date all of the required

information and appropriate signatures have been finalized on an option. For example, an

assessment may be started on 5/11/13; however, this assessment isn’t finalized until 6/12/13. In

this example the valid date of the assessment is 6/12/13.

GLOSSARY

Return to Top of Section Return to Table of Contents Return to Top of Section Return to Table of Contents

129

INCLUDED DIAGNOSES

The following DSM-IV-TR disorders qualify for a primary diagnosis:

Pervasive Developmental Disorders, except Autistic Disorders

Disruptive Behavior and Attention Deficit Disorders

Feeding and Eating Disorders of Infancy or Early Childhood

Elimination Disorders

Other Disorders of Infancy, Childhood, or Adolescence

Schizophrenia and Other Psychotic Disorders, except Psychotic Disorders due to a

General Medical Condition

Mood Disorders, except Mood Disorders due to a General Medical Condition

Anxiety Disorders, except Anxiety Disorders due to a General Medical Condition

Somatoform Disorders

Factitious Disorders

Dissociative Disorders

Paraphilias

Gender Identity Disorder

Eating Disorders

Impulse-Control Disorders Not Elsewhere Classified

Adjustment Disorders

Personality Disorders (Axis II), excluding Antisocial Personality Disorder

Medication-Induced Movement Disorder related to other included diagnoses

Appendix

MEDICAL NECESSITY CRITERIA - DIAGNOSES

A Back to Section III

Return to Top of Section Return to Table of Contents

120

EXCLUDED DIAGNOSES

The following DSM-IV-TR disorders do not qualify for a primary diagnosis:

Autistic Disorder

Learning Disorders

Motor Skill Disorders

Communication Disorders

Tic Disorders

Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Mental Disorders Due to a General Medical Condition

Substance-Related Disorders

Sexual Dysfunctions

Sleep Disorders

Other conditions that may be a focus of clinical attention, except Medication-

Induced Movement Disorders

Mental Retardation (Axis II)

Antisocial Personality Disorder (Axis II)

799.9 Deferred diagnosis

V71.09 No diagnosis

Return to Top of Section Return to Table of Contents

121

NAME OF DOCUMENT INITIALLY COMPLETED UPDATED

Consent for Treatment Obtained the day of the first face-to-face contact.

Annually+

Advanced Directive (Adults Only)

Discuss with client (complete form if client requests Advanced Directive).

Not Required +

Member Information Brochure

Given to client on the day of the first face-to-face contact.

Not Required

Acknowledgement of Receipt of Notice of Privacy Practices

Obtained the day of the first face-to-face contact.

Not required+

Patients’ Rights Brochure Offered the day of the first face-to-face contact.

Not Required

Acknowledgement of Receipt of Medi-Cal Handbook

Offered Medi-Cal Handout the day of the first face-to-face contact.

Not required+

Pay or Financial Information Form (PFI) – 2 pages

Obtained the day of the first face-to-face contact.

Annually or if situation changes

Client Registration (Client Demographics Data) – 2 pages

Obtained the day of the first face-to-face contact.

Annually (or if client moves)

Client CSI Data (CA State Info)

Given to client on the day of the first face-to-face contact.

Annually

Emergency Contact Information Form

Obtained the day of the first face-to-face contact.

Annually

Release of Information (Authorization for Use or Disclosure of Protected Health Information)

As needed to obtain, disclose, or exchange protected health information.

Annually (unless otherwise specified in release or updated as needed)

Episode Opening and Period Information/Last Page of Assessment (For Contract Providers only)

Completed at first visit. Annually or rewritten to update changes

Assessment Bundle Within 60 days of opening. Annually – May be updated as needed

+ Unless legal status changes – i.e. Youth turns 18 or conservatorship or ward/dependent of the court, etc.

Appendix

BCDBH CHART PAPERWORK TIMELINES

B Back to Section IV Back to Section V

Return to Top of Section Return to Table of Contents

122

NAME OF DOCUMENT INITIALLY COMPLETED UPDATED Client Treatment Plan No later than 60 days from

opening date. Until a client plan is finalized with necessary signatures, the only services that can be provided are assessment, plan development, and crisis intervention.

Annually – May be updated at any time

Progress Notes For each client contact. N/A

Consent for Psychotropic Medication Therapy

By M.D. or prescribing nurse when medication is prescribed.

Completed when a new medication is added

Medication Order Sheet By M.D. or prescribing nurse when medications are prescribed.

Whenever meds are added, refilled, or discontinued

Therapeutic Behavioral Services (TBS) Referral

When a client who is eligible is referred.

N/A

Client Discharge Complete at time of last service with client to close or transfer case. Discharge diagnosis is entered as well as completing MyAvatar Discharge option

N/A

NOA (A B C D E ) Complete NOA in MyAvatar when client meets criteria (See NOA Summary)

N/A

*Forms in all sections should be in chronological order with the most current on top*

Return to Top of Section Return to Table of Contents

123

3030 BROKERAGE/TARGETED CASE MANAGEMENT: services that assist a beneficiary to access needed medical, alcohol and drug treatment, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities include: communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and plan development.

3110 COLLATERAL: services to one or more significant support persons in the life of the client for the purpose of improving or maintaining the mental health of the client. Progress notes must address the goals and interventions on the client plan.

3112 GROUP COLLATERAL: services provided to a group of ‘significant support persons’ of client’s receiving direct mental health services. Client is not present. Used primarily in relation to youth (under 18 clients) - though not exclusively. The group activity is education and interventions that help the significant support people improve the client’s functional impairments and/or assist in minimizing the impact of mental illness on client functional impairments. The primary focus cannot be support for the parent, significant other, etc. Progress notes should include the number of clients represented - not the number of significant support people who are present. Example: there are 7 significant support people present in the group, but they represent 5 clients. The note would reflect 5 clients were benefitting from the group. Progress notes must address the goals and interventions on the client plan.

3310 ASSESSMENT AND EVALUATION: service activity with a client that formulates a clinical analysis of the history and current status of the client’s mental, emotional, or behavioral disorder, including relevant cultural issues. Assessment may include diagnosis and testing procedures (includes performance outcome measures).

Appendix

BUTTE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH PROCEDURE CODE DEFINITION:

DIRECT SERVICES

C

Return to Top of Section Return to Table of Contents

124

3410 INDIVIDUAL THERAPY: face-to-face (F2F) service time (client is present) is from 1 - 37 minutes. Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments. Can include ‘Family Therapy’ with client present. Progress notes must address the goals and interventions on the client plan.

3412 INDIVIDUAL THERAPY: F2F service time (client is present) is from 38 -52 minutes. Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments. Can include ‘Family Therapy’ with client present. Progress notes must address the goals and interventions on the client plan.

3414 INDIVIDUAL THERAPY: F2F service time (client is present) is from 53 - 480 minutes. Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments. Can include ‘Family Therapy’ with client present. Progress notes must address the goals and interventions on the client plan.

3415 INDIVIDUAL THERAPY: a “non face-to-face” direct service activity (the client is not physically present – perhaps telephone, etc.). Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments. Can include ‘Family Therapy’ with client present. Progress notes must address the goals and interventions on the client plan.

3450 REHABILITATION SERVICES: counseling and other services with a client which address functional impairments: improve, maintain, or restore a functional skill, daily living skill, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication education. Progress notes must address the goals and interventions on the client plan.

3510 GROUP THERAPY: services provided to a group of clients that focus on symptom reduction as a means to improve functional impairment. Progress notes must include the number of clients in the group and address the goals and interventions on the client plan.

3570 GROUP REHABILITATION SERVICES: services provided to a group of clients which address functional impairments: improve, maintain, or restore a functional skill, daily living skill, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication education. Progress notes must include the number of clients present and address the goals and interventions on the client plan.

3710 CRISIS INTERVENTION: “face-to-face” (F2F) service time (client physically present) is between 1-44 minutes. Unplanned services that require a more

Return to Top of Section Return to Table of Contents

125

timely response than a regularly scheduled visit Progress notes need not address the client plan goals and interventions; notes must document the nature and severity of the crisis, staff interventions to manage the crisis, and follow-up plans. Multiple contacts may be documented in a single note and contacts with collateral individuals may be included.

3715 CRISIS INTERVENTION: a “non face-to-face” direct service activity (the client is not physically present - perhaps telephone, etc.). Unplanned services that require a more timely response than a regularly scheduled visit Progress notes need not address the client plan goals and interventions; notes must document the nature and severity of the crisis, staff interventions to manage the crisis, and follow-up plans. Multiple contacts may be documented in a single note and contacts with collateral individuals may be included.

3910 PLAN DEVELOPMENT: service activity, which consists of the development of client plans, the approval of client plans, and/or monitoring of a beneficiary’s progress. Progress notes should state that the client plan goals and interventions were developed, updated, progress toward the goals, or how the interventions will be implemented.

Return to Top of Section Return to Table of Contents

126

3610 MEDICATION SUPPORT: a “non face-to-face” direct service activity (the client is not present). This code is used primarily for two Medi-Cal claimable activities: developing and writing a medication client plan (med support Plan Development); or medication monitoring services including review of recent lab reports, medication renewal orders, etc.

3630 MEDICATION SUPPORT- MENTAL HEALTH SERVICE non-prescriber code: F2F service time (client physically present) This code is to be used by none-prescribing medical staff for ongoing assessment, administration of medications, etc.

90792 ASSESMENT MHS SERVICES W/MEDICAL SERVICES: “face-to-face” (F2F) service time (client physically present) Psychiatric diagnostic evaluation with medical services is an integrated biopsychosocial and medical assessment, including history, mental status, other physical examination elements as indicated, and recommendations. – The evaluation may include communication with family or other sources, prescription of medications, and review and ordering of laboratory or other diagnostic studies. Diagnostic Evaluation/Assessment MH Svc w/ Medical Services (old = 90801)

99213 MEDICATION SUPPORT- MENTAL HEALTH SERVICE Evaluation/Management for Established Patients – Detail History/Examination for mild to moderate complexity (primary care level or stable mentally ill) (old 90804, 90806, 90808): MEDICATION SUPPORT: F2F service time (client physically present). This code is to be used by psychiatrists and Family Nurse Practitioners (individuals who have prescriptive authority) for ongoing assessment, prescription, administration of medications, etc.

99214 MEDICATION SUPPORT- MENTAL HEALTH SERVICE

Evaluation/Management for Established Patients – Comprehensive

History/Examination for moderate to severe complexity (unstable chronically

mentally ill) (otherwise the same as 99213)

90833 PSYCOTHERAPY 1-37 MINUTES Add on code (added to 99213/99214 if psychotherapy was included). From old above (crossed out) “but also includes a substantial psychotherapy component.”

90836 PSYCOTHERAPY 38-52 MINUTES Add on code (added to 99213/99214 if psychotherapy was included). From old above (crossed out) “but also includes a substantial psychotherapy component.”

PROCEDURE CODES FOR MEDICAL STAFF

Return to Top of Section Return to Table of Contents

127

90838 PSYCOTHERAPY 53 -1440 MINUTES Add on code (added to 99213/99214 if psychotherapy was included). From old above (crossed out) “but also includes a substantial psychotherapy component.”

M0064 MEDICATION SUPPORT Brief (1-15 minutes) – F2F service time (client physically present) is between 1-15 minutes. This code is to be used by any licensed medical staff (MD, FNP, RN, LVN, LPT) where the primary purpose includes ongoing assessment, prescription, administration of medications, etc.

Return to Top of Section Return to Table of Contents

128

Procedure Codes for Special Populations

3230 THERAPEUTIC BEHAVIORAL SERVICES (TBS): This includes all services relating to TBS including direct service, plan development, and collateral contacts with the family. Progress notes must address the goals and interventions on the TBS client plan. One note per shift. This code is used primarily by contractors providing TBS and should not be used by clinicians who are responsible for delivering the mandatory co-occurring mental health services (therapy, rehab, etc.).

3040 INTENSIVE CARE COORDINATION (ICC) – KATIE A: intensive care coordination (ICC) is a targeted case management (TCM) service that facilitates assessment of, care planning for and coordination of services, including urgent services for members of Katie A. Subclass (see Medi-Cal Manual for Intensive Care Coordination, Intensive Home Based Services & Therapeutic Foster Care for Katie A. Subclass Members – Appendix D (pg 22) in the Manual for a more detailed description of ICC).

Katie A Subclass Member Medi-Cal Manual

3420 INTENSIVE HOME BASED SERVICES (IHBS) – KATIE A: intensive home-based mental health services (IHBS) are mental health rehabilitation services provided to members of the Katie A. Subclass. IHBS are individualized, strength-based interventions designed to ameliorate mental health conditions that interfere with a child/youth’s functioning and are aimed at helping the child/youth build skills necessary for successful functioning in the home and community and improving the child/youth’s family ability to help the child/youth successfully function in the home and community (see Medi-Cal Manual for Intensive Care Coordination, Intensive Home Based Services & Therapeutic Foster Care for Katie A. Subclass Members – Appendix D (pg 26) in the Manual for a more detailed description of IHBS).

Katie A Subclass Member Medical Manual

PROCEDURE CODES FOR SPECIAL POPULATIONS

WEB

DELL

LINK

DELL

WEB

DELL

LINK

DELL

Return to Top of Section Return to Table of Contents

129

Procedure Code Definitions: Direct Services - “Lock out” Settings

The following service codes capture direct service activity delivered in settings that do not allow conventional funding stream billing (Medi-Cal, etc.) including Juvenile Hall, Jail, Psychiatric Inpatient Hospitals, etc. Staff should use these codes only after approval and consultation with their Program Manager /Clinical Supervisor.

6030 (NO MCAL) BROKERAGE/TARGETED CASE MANAGEMENT: Services that assist a beneficiary to access needed medical, alcohol and drug treatment, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities include: communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and plan development.

6110 (NO MCAL) COLLATERAL: Services to one or more significant support persons in the life of the client for the purpose of improving or maintaining the mental health of the client. Progress notes must address the goals and interventions on the client plan.

6300 (NO MCAL) ASSESSMENT AND EVALUATION: Service activity with a client that formulates a clinical analysis of the history and current status of the client’s mental, emotional, or behavioral disorder, including relevant cultural issues. Assessment may include diagnosis and testing procedures (includes performance outcome measures).

6410 (NO MCAL) INDIVIDUAL THERAPY ( 1-37 MINUTES F2F): Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments; includes Family Therapy with client present. Progress notes must address the goals and interventions on the client plan.

6412 (NO MCAL) INDIVIDUAL THERAPY (38-52 MINUTES F2F): Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments; includes Family Therapy with client present. Progress notes must address the goals and interventions on the client plan.

PROCEDURE CODES DEFINITIONS: DIRECT SERVICES – “LOCK OUT” SETTINGS

Return to Top of Section Return to Table of Contents

130

6414 (NO MCAL) INDIVIDUAL THERAPY (53+ MINUTES F2F): Therapeutic interventions with a client that focus primarily on symptom reduction as a means to improve functional impairments; includes Family Therapy with client present. Progress notes must address the goals and interventions on the client plan.

6415 (NO MCAL) INDIVIDUAL THERAPY (NON FACE-TO-FACE): Therapeutic interventions with a client not physically present (telephone, etc.) that focus primarily on symptom reduction as a means to improve functional impairments; includes Family Therapy when client not present. Progress notes must address the goals and interventions on the client plan.

6450 (NO MCAL) REHABILITATION SERVICES: Counseling and other services with a client which address functional impairments: improve, maintain, or restore a functional skill, daily living skill, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication education. Progress notes must address the goals and interventions on the client plan.

6510 (NO MCAL) GROUP THERAPY: Services provided to a group of clients that focus on symptom reduction as a means to improve functional impairment. Progress notes must include the number of clients in the group and address the goals and interventions on the client plan.

6570 (NO MCAL) GROUP REHABILITATION SERVICES: Services provided to a group of clients which address functional impairments: improve, maintain, or restore a functional skill, daily living skill, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication education. Progress notes must include the number of clients present and address the goals and interventions on the client plan.

6630 (NO MCAL) MEDICATION SUPPORT:

6710 (NO MCAL) CRISIS INTERVENTION (1-74 MINUTES F2F): Unplanned services that require a more timely response than a regularly scheduled visit Progress notes need not address the client plan goals and interventions; notes must document the nature and severity of the crisis, staff interventions to manage the crisis, and follow-up plans. Multiple contacts may be documented in a single note and contacts with collateral individuals may be included.

6715 (NO MCAL) CRISIS INTERVENTION: (NON FACE-TO-FACE): Unplanned services that require a more timely response than a regularly scheduled visit but the client is not physically present (telephone, etc.) Progress notes need not address the client plan goals and interventions; notes must document the

Return to Top of Section Return to Table of Contents

131

nature and severity of the crisis, staff interventions to manage the crisis, and follow-up plans. Multiple contacts may be documented in a single note and contacts with collateral individuals may be included.

6910 (NO MCAL) PLAN DEVELOPMENT: Service activity, which consists of the development of client plans and the approval of client plans. Progress notes should state that the client plan goals and interventions were developed, updated, progress toward the goals, or how the interventions will be implemented.

Return to Top of Section Return to Table of Contents

132

4000 NO SHOW: to be used when a client is scheduled and does not show up at the appointment time. Essentially an “information note” attached to a client record. Staff may use up to 15 minutes to account for this incident.

4010 INFORMATIONAL NOTE: documentation of a client interaction or activity that cannot be accounted for as a direct service, buts needs to be included in the client record.

4060 CLIENT SUPPORT: an activity or contact not eligible to be reported as treatment or outreach. Support may include housing support, recreation, respite care or social support that does not fall under 2410 Day Treatment Socialization. This code is used when other available codes have been ruled out.

4110 MH PROMOTION: any activity that informs, educates, clarifies, etc. mental health services to the general public or to other agencies. Not to be used instead of 4780.

4210 COMMUNITY CLIENT SERVICE (NON-OPENED CASES): activities directed toward: 1) assisting clients and families for whom there is no open case record to achieve a more adaptive level of function through single contact or occasional contact, or 2) enhancing or expanding the knowledge and skills of human service agency staff in meeting the needs of mental health clients.

4250 CRISIS “ON DUTY”: used to record time spent on the crisis line and as backup counselor when no other activity code can be used to capture this time.

4270 CRISIS STABILIZATION INFO NOTE: documentation of a client interaction or activity that cannot be accounted for as a direct service, buts needs to be included in the client record. No specific staff time is included.

4421 SUPERVISION OF STUDENT INTERNS: to be used by clinical line staff for direct time spent in oversight of student intern activity.

4560 PHF ON DUTY: used to account for staff time when they have been temporarily assigned to work a shift on the PHF.

PROCEDURE CODES DEFINITIONS – INDIRECT SERVICES

Return to Top of Section Return to Table of Contents

133

4580 CSU ON DUTY: used to account for staff time when they have been temporarily assigned to work a shift on the CSU.

4770 SAMHSA ACTIVITIES: SAMHSA related activities not eligible to be reported as treatment or outreach which are provided by staff supported by the general SAMHSA grant. This code identifies staff time that should be billed to the grant.

4780 GENERAL ADMINISTRATIVE ACTIVITIES: used to record any non-client billable activity that is not captured in any other indirect code.

4790 TIME OFF: any time off, whether paid or Leave Without Pay.

4890 “MEDI-CAL QUALITY” MANAGEMENT: used to record time directly related to the Utilization Review activities in association with, and under the direction of, Quality Management (QM)/Quality Improvement (QI) programs (e.g. participation in monthly QM/QI Committees, inpatient & outpatient authorizations, audits, and assigned QA activities).

Return to Top of Section Return to Table of Contents

134

4970 MHSA Community Support Services (CSS): Activities, non-direct Mental Health Service, within approved MHSA programs.

4971 MHSA Workforce Education Training (WET)

4972 MHSA Prevention & Early Intervention (PEI)

4973 MHSA Capitol Information Technology (CapIT)

4974 MHSA Housing

THE FOLLOWING SERVICE CODES ARE FOR IDENTIFIED MHSA PLANNING PERSONNEL - USE IS LIMITED/RESTRICTED

TO DESIGNATED STAFF ONLY

Return to Top of Section Return to Table of Contents

135

1. WHAT WAS THE REASON OR PURPOSE OF THE ENCOUNTER? Start by describing the type of service e.g. individual, collateral, etc.

2. WHAT WAS THE CONTENT OR TOPICS DISCUSSED?

Factual, brief, and relevant to the goals and objectives if possible

3. WHAT CLINICAL OBSERVATIONS WERE MADE?

Should be objective, factual, and non-judgmental

4. WHAT IS THE CURRENT MEDICAL NECESSITY FOR SERVICES?

Please remember we need to demonstrate continued medical andservice necessity for the level of services that are provided

Was the service provided appropriate to address the client’s serviceneed?

5. WHAT WAS SAID, DONE OR REQUESTED BY THE CLIENT?

This is a good place to address requests for linguistic services

1. WHAT DID YOU DO IN THE CONTEXT OF THE ENCOUNTER?

Example: Address what was done about the request for linguisticservices cited above

2. WHAT THERAPEUTIC INTERVENTIONS OR TECHNIQUES WEREEMPLOYED?

These hopefully reflect the ones listed in the client plan, if not addresswhy there was a deviation from the plan

Appendix

FORMAT FOR PROGRESS NOTES

D

DESCRIBE

4.

2.

1.

5.

3.

INTERVENTION

2.

1.

Return to Top of Section Return to Table of Contents

136

3. WHAT PROGRESS OR SETBACKS OCCURRED?

Describe in measurable, behavioral terms progress toward the goal andaddress possible reason for lack of progress

4. WHAT REFERRALS WERE MADE?

If any referrals were made, please address them here

1. WHAT WAS THE CLIENT’S RESPONSE TO THE INTERVENTION?

Address this in specific terms based on behavior or client report

2. HOW WAS THE INTERVENTION EFFECTIVE OR INEFFECTIVE?

Describe in terms of measurable or observable changes in behavior wheneverpossible

3. WHAT SIGNS OR SYMPTOMS OF THE DIAGNOSIS ARE PRESENT OR NOLONGER PRESENT?

This goes to medical necessity and accuracy of current treatment

4. WHAT WAS DONE OUTSIDE THE SESSION?

If homework was given at the previous session this is a good place to addresswhat the client did or did not accomplish

If the client self-initiated any interventions, report them as well (e.g. joining aself-help group)

5. WHAT ARE THE CLIENT’S CURRENT IMPAIRMENTS AND STRENGTHS?

Again, this addresses medical and service necessity and should describecurrent levels of functional impairments and strengths to overcome them

1. HOW DID THE SESSION ADDRESS TREATMENT PLAN OBJECTIVES?

Based on what was described above, describe how you helped the client’s therecovery process

4.

3.

RESPONSE

TREATMENT PLAN

4.

2.

1.

5.

3.

1.

Return to Top of Section Return to Table of Contents

137

2. WHAT WILL BE DONE OUTSIDE THE SESSION?

Describe any activities that will occur before the next contact, e.g. planned,referrals, etc.

3. WAS THERE HOMEWORK ASSIGNED?

Did you teach the client a new adaptive skill and is there an expectation that itwill be practiced before the next session

4. WHAT TYPE OF FOLLOW UP WILL BE MADE?

Similar to above, could consist of planned collateral contacts. State the

planned time for the next contact with the client

4.

2.

3.

Return to Top of Section Return to Table of Contents

138

Service Site or During the Hours of Operation

Lock-out Mental Health Service

Lock-out Medication Support Services

Lock-out Targeted Case Management Services

Crisis Residential Yes1 No No

Crisis Stabilization (CSU) Yes2 Yes No

Day Programs (Intensive and Rehabilitation)

No3 Yes No

Juvenile Hall, Jail, or Similar Detention (not adjudicated for Placement)

Yes4 Yes3 Yes3

Psychiatric Inpatient Hospital Yes1, 4 Yes Yes4

Psychiatric Health Facility (PHF) Yes1 Yes Yes5

Psychiatric Nursing Facility Yes1 Yes Yes5

Physical Health Care Hospital No No No

For ICC and IHBS, see Medi-Cal Documentation Manual for lock-outs

CDSS Medi-Cal Manual for ICC and IHBS

1 Except on the day of admission 2 No other Specialty Mental Health Service is reimbursable during the same time period the service is reimbursed 3 Except by the same Day Treatment Program Staff 4 Except on the day of admission, and 30 calendar days or less per continuous stay in the facility immediately prior to discharge for the purpose of placement 5 Except on the day of admission, and 30 calendar days immediately prior to the day of discharge, for a maximum of three non-consecutive periods of 30 calendar days or less per continuous stay in the facility immediately prior to discharge for the purpose of placement.

*Adapted from CIMH EPSDT Manual Lock-Out Crosswalk (Lisa Scott-Lee, 2007)

TYPE OF SERVICE

Appendix

BILLING LOCK-OUT GRID

E Back to Section X Back to Section VIII

Return to Top of Section Return to Table of Contents

LINK

DELL

LINK

DELL